BG giải phẩu bệnh Y phạm ngọc thạch

Chu nhiem bo mon : Gs.Ts.Bs.
NGUYEN SAO TRUNG

Giang vien : Ts.Bs. AU NGUYET DIEU
Ths.Bs. BUI TH HONG KHANG
Ths.Bs. HUYNH NGOC LINH
Bs. BUI HUYNH QUANG MINH
Bs.CKII. TRNG CONG PHIET
Bs. ANG HOANG ANH TH
Ths.Bs. NGUYEN NH TUAN
CN. LE TH THANH HUYEN
CN. TRIEU TH XUAN THU
Bc tng go nho c thay trong mot tiem cam o pho Bronx thanh pho
New York, tac hnh nha benh hoc noi tieng ngi c Rudolf Virchow, vi
hang ch "Pathologe... nd am Ende steht der Erfolg !" ngha la " Nha nghien
cu benh hoc... cuoi cung cung se thanh cong !"
MUC LUC
****
PHAN I: GIAI PHAU BENH AI CNG
Chng 1 GII THIEU VE MON HOC GIAI PHAU BENH 1

Chng 2 TON THNG C BAN CUA TE BAO VA MO 11
Chng 3 VIEM VA SA CHA 33
Chng 4 BENH LY U 55
Chng 5 TON THNG HUYET QUAN - HUYET 97
PHAN II: GIAI PHAU BENH CHUYEN BIET
Chng 6 BENH LY HE TIM MACH 111

Chng 7 BENH LY HE HO HAP 137
Chng 8 BENH LY ONG TIEU HOA 161
Chng 9 BENH LY GAN 189
Chng 10 BENH LY HE SINH DUC N 205
Chng 11 BENH LY TUYEN VU 239
Chng 12 BENH LY TUYEN GIAP 255
Chng 13 BENH LY HE SINH DUC NAM 271
Chng 14 BENH LY THAN 287
Chng 15 BENH LY HACH LIMPHO 311
Chng 16 BENH LY XNG - KHP - PHAN MEM 333
PHAN III: TAI LIEU THAM KHAO 365

PHU LUC : ieu kien thi, thang iem 367
GIAI PHAU BENH AI CNG
Gii thieu mon hoc Giai phau benh 1
GII THIEU VE MON HOC GIAI PHAU BENH
oi dong ve lch s phat trien mon giai phau benh
Theo ngha rong, giai phau benh la mon hoc nghien cu ve benh tat, va y niem ve benh tat
th khong ngng thay oi trong suot lch s phat trien cua nhan loai, ke t khi con ngi bat au
xuat hien tren mat at nay cach ay na trieu nam. Vao thu hong hoang, ngi nguyen thuy tin
rang benh tat xay ra la do con ngi a pham phai cac ieu cam k, lam phat y than linh hoac b
ke thu tru em... cho nen e khoi benh th phai xng thu toi loi, thc hien mot so nghi le cung te
hoac tr ta nao o; con neu chang may b thng trong khi san bat th ch biet cha bang cach
ap la hoac le li liem lap !... (Hnh 1)
Hnh 1: Ngi nguyen thuy song trong hang ong, khi b thng th c cha bang cach liem lap !
Ngi Ai cap co ai a thc hien hang trieu trng hp p xac ma trong o, cac noi tang
eu c lay ra khoi c the ngi chet, nhng khong co bat ky ghi chu nao ve qua trnh thc hien
viec o c lu lai. Ngi Hy lap co ai cung khong co y niem nao ro ret hn ve nguyen nhan
va c che phat sinh benh tat, ngoai mot vai quan sat gian n ve cac vet thng va u bu.
Mot thay thuoc Hy lap co ai c biet en nhieu nhat co ten la Hippocrates, c xem la
ong to cua Tay Y; ong sinh vao nam 460 trc Cong nguyen (Tr CN) tai ao Cos, vung Tieu A.
Hippocrates tin rang con ngi c tao thanh t 4 yeu to la kh, nc, la, va at, tng ng vi
4 loai the dch trong ngi la mau, chat nhay, mat vang va mat en; benh tat la do s mat can
bang cua 4 loai the dch nay va co tac ong len toan the con ngi ch khong rieng mot c
quan nao. La ngi theo chu ngha kinh nghiem, ong luon yeu cau cac hoc tro phai ac biet chu
trong en khau hoi benh va tham kham benh nhan e co bien phap cha tr thch hp. (Hnh 2)
Hnh 2: Hippocrates ang cha benh dch hach tai thanh Athens; mot manh giay coi c viet vao nam
275 sau cong nguyen, ghi lai li the Hippocrates.
Trong ieu tr, ong thc hien c mot so thu thuat ngoai khoa nh x tr vet thng, nan
xng gay, trch mau, tay xo va bao che mot so thuoc co nguon goc t khoang chat, thao moc va
ong vat. D nhien vi cach luan benh va phng tien ieu tr nh vay th co le khong co may
benh c cha khoi, nh ong a tha nhan: Mot thay thuoc chan chnh ch oi khi cha khoi
benh, thng lam bt benh nhng luon biet an ui benh nhan. Ong noi tieng la ngi a thiet nh
cac nguyen tac ve y c ma ngay nay van con c biet en di ten goi Li the Hippocrates.
Ong mat nam 377 (Tr CN).
Sau Hippocrates, triet gia Hy lap Platon (428-348 Tr CN) trong tac pham oi thoai cua
mnh, cung tin con ngi c tao thanh t la, nc, at va kh nhng theo ong, kh mi la yeu
to chnh lam cho cac bo phan hoat ong va tao ra s song.
Triet gia Aristote (384-322 Tr CN), co tinh

than thc nghiem hn nhng do viec mo xac
ngi b cam nen a da vao cac phau tch ong
vat e suy dien sang ngi, chang han ong cho
rang tim ngi co 3 buong! Na the ky sau o tai
Alexandrie cua Ai cap, Herophile va Erasistrate la
nhng ngi au tien dam lieu thc hien phau
tch tren ngi e nghien cu va a nh chnh
cac ket luan sai lam cua Aristote; hai ong at
c nhieu thanh qua ang ke trong lanh vc giai
phau hoc nhng rat tiec khong c cac ong
Hnh 3: Herophile ang mo xac
nghiep quan tam chu y. (Hnh 3)
en au the ky I, mot hoc gia La ma ten

Cornelius Celsus, a bien soan nhieu sach ve u
moi lanh vc nh nong nghiep, tu t hoc, binh
phap va y hoc. Trong bo sach Ve y hoc (De
medicina), ong phan biet benh tat thanh 3 nhom
tuy theo cach cha tr bang che o an, thuoc
hoac phau thuat; ong a mo ta trieu chng cua
mot so benh tim, tam than va ac biet a ghi
nhan ay u 4 trieu chng cua hien tng viem la
sng, nong, o va au. (Hnh 4)
Hnh 4: Cornelius Celsus
Bc sang the ky II, mot thay thuoc La ma
khac ten Claudius Galen (130-200), la ngi phu
trach cham soc sc khoe cho cac vo s giac au,
nh vay co ieu kien quan sat mot so loai ton
thng. Ong cho rang benh tat xuat phat t ton
thng cua mot c quan, mot tang nao o; nhng
van gi lai quan niem roi loan the dch cua
Hippocrates. Ong viet rat nhieu sach nghien cu
ve giai phau hoc, sinh ly hoc, dinh dng hoc,
triet hoc. Ong co nhieu ngi ham mo trong o co
Hoang e La ma Marcus Aurelius, ngi a khen
ngi ong la bac nhat cua cac thay thuoc va triet Hnh 5: Claudius Galen
gia. (Hnh 5, 6)
Do at c uy tn qua ln nh vay nen cac sach giai phau hoc cua ong a c xem la
chan ly va c s dung trong giang day y khoa suot hang ngan nam, en tan the ky th XVI;
mac du cac mo ta ve giai phau ngi cua ong cha ng nhieu sai lam do da chu yeu vao cac
cuoc phau tch tren heo, de, vn, voi.
Hnh 6: Galen ang mo heo; giang day mon sinh; hng dan thut thao benh nhan; Sach cua Galen a c
dung trong suot thi ky trung co.
Trong thi ky trung co (the ky V-XV), y hoc va triet hoc thng tron lan vi nhau. Viec chan
oan va ieu tr benh khong co thay oi ang ke, phau tch tren ngi van b cam k; tuy nhien
cung co mot so tien bo can phai ghi nhan nh viec thanh lap cac benh vien t the ky IV, khi au
tai Syri roi lan rong khap e quoc Byzantin; s ra i cua cac trng ai hoc y khoa t the ky XII,
bat au tai Y va sau o la Tay ban nha, Anh va Phap.
en the ky XVI, bat au thi ky phuc hng, hoat ong nghe thuat va nghien cu khoa hoc
ke ca y hoc hoi sinh manh me. Mot ngi Ha lan ten Andreas Vesalius (1514-1564), sau khi tot
nghiep ai hoc Y khoa Padua Y, a c gi lai lam Giao s ve giai phau hoc. Sau nhieu nam
phau tch t m xac chet, ong cho xuat ban vao nam 1543 bo sach Ve cau tao c the ngi (De
humani corporis fabrica); trong o a sa lai cac sai lam cua Galen. Vesalius c xem la cha e
cua mon giai phau hoc. (Hnh 7)
Hnh 7: Andreas Vesalius, tac gia cua bo sach Ve cau tao c the ngi
Giovani Batista Morgagni (1685-1771), mot thay thuoc ngi Y, c xem la ngi khai sinh ra
mon hoc giai phau benh. Tong ket kinh nghiem mot i lam viec, nam 79 tuoi, ong cho xuat ban
cuon sach Ve v tr va nguyen nhan cua benh tat, nghien cu bang giai phau hoc (De sedibus,
et causis Morborum per anatomen indagatis) trong o trnh bay ket qua phau tch 700 trng hp
t vong. Theo ong, moi benh tat la benh ly cua c quan; moi benh nhan, benh se co v tr
nhng c quan khac nhau. Ong a phan tch t m moi lien he gia cac trieu chng lam sang cua
tng benh nhan vi ton thng ai the quan sat c tren c quan. ay thc s la mot tien bo
trong nghien cu ve benh tat, nhng do s hieu biet ve sinh ly hoc thi o con nhieu han che nen
ong van khong ly giai c v sao benh ly cua c quan nay lai co the tac ong en mot c quan
khac trong c the. (Hnh 8)
Hnh 8: G.B.Morgagni va cuon sach Ve v tr va nguyen nhan

cua benh tat, nghien cu bang giai phau hoc
Nha giai phau benh xuat sac tiep theo la Giao s Karl Rokitansky (1804-1874), ngi Tiep
khac, lam tai Benh vien a khoa thanh Vien cua nc Ao. c chnh quyen bo nhiem lam ngi
mo kham nghiem t thi cho tat ca cac trng hp t vong, ong a thc hien c tong cong
30.000 trng hp (trung bnh moi ngay 2 trng hp trong suot 45 nam!). Cung vi ong nghiep
la Giao s noi khoa Joseph Skoda, ong a oi chieu lam sang vi giai phau benh va uc ket
thanh mot bo sach benh hoc gom 3 tap. Thc ra, ca hai ong eu khong hieu biet ch xac ve
nguyen nhan gay benh va c che benh sinh, van tin theo thuyet roi loan the dch t thi
Hippocrates, va nh vay viec ieu tr khong thc s hieu qua; bi the Giao s Skoda thng noi
vi sinh vien rang: Chan oan mi la tat ca, con ieu tr th hay quen i. (Hnh 9)
Hnh 9: Giao s K.Rokitansky va J.Skoda
Rudolf Virchow (1821-1902), Giao s benh hoc tai Berlin, c; tuy voc dang nho be nhng
lai la mot nha nghien cu benh hoc ln nhat cua moi thi ai. Cuon Benh hoc te bao do ong
viet nam 1858 c xem la c s cua mon giai phau benh hien ai; trong o ong a mo ta ay
u cac hnh thai ton thng c ban nh ph ai, tang san, chuyen san, phan ng viem, nhoi mau,
u (Hnh 10). Theo ong, nguon goc cua moi benh tat eu xuat phat t cac hoat ong bat thng
cua te bao. Nh vay vi Virchow, s hieu biet ve benh tat a tien them mot bc, t cac ton
thng c quan sang ton thng mc o te bao. Ong co nhieu hoc tro gioi, trong o phai ke
en Julius Cohnheim (1839-1884), la ngi a co cac nghien cu sau ve phan ng viem va la

ngi au tien phat hien ra hien tng xuyen mach. (Hnh 11)
Hnh 10: Giao s Rudolf Virchow va cuon sach Benh hoc te bao Hnh 11: Giao s Julius Cohnheim
Trong thi ai cua Virchow, cac thay thuoc van cha

hieu biet nhieu ve kha nang gay benh cua cac vi sinh vat;
va Louis Pasteur (1843-1910), tuy xuat than la mot nha
hoa hoc, lai chnh la ngi a tao ra mot cuoc cach mang
trong nghien cu benh hoc. Qua viec giai quyet thanh
cong nhieu benh khac nhau nh benh tam gai, benh than
cu, benh cho dai; ong la ngi au tien a chng minh
co the dung phng phap thc nghiem e tm ra nguyen
nhan phat sinh dch benh va t o co cac bien phap phong
chong thch hp.
T gia the ky XX, nghien cu benh tat a tien sang

mc o phan t, bat au vi viec tm ra nguyen nhan cac
benh roi loan chuyen hoa bam sinh. Con ngi a at
c nhng thanh tu het sc to ln trong viec tm hieu
ban chat benh tat, nguyen nhan gay benh va c che benh Hnh 12: Louis Pasteur
sinh.
D an giai ma bo gen ngi (human genome project) - mot d an a quoc gia khi s t
1987 - a gan nh hoan tat va a phat hien bo gen ngi cha khoang 34.000 gen; mot d an
khac cung ang c tien hanh nham lap nen th vien cac protein ngi (Proteomics), xac nh
mang li tng tac gia cac protein trong te bao. Tham vong cua cac nha khoa hoc - nh a
c dien ta trong mot bo phim khoa hoc vien tng mang ten Gattaca (1997) (Hnh 13) - la ch
Hnh 13: Phim khoa hoc vien tng Gattaca (1997)

can mot giot mau lay t c the benh nhan, a co the xac nh c gen nao co cau truc va chc
nang b roi loan, protein nao b h hong, t o co bien phap ieu tr ac hieu ngay tai phan t
ch nay (Targeted therapy).
au the ky XXI nay, du a co vo so tien bo khoa hoc, s tch hp cua tin hoc vao moi
mat cua i song, s d tha cua cai vat chat... nhng hnh nh con ngi van khong cam thay
hanh phuc hn cha anh cua ho. S bung no cac loai dch benh mi (AIDS, cum ga, SARS, cum
heo), van nan o nhiem moi trng, s nong len cua trai at, ho sau ngan cach giau ngheo, cac
cuoc chien tranh ln nho, nan khung bo... cang lam cho con ngi cua thi hau hien ai nay
cam thay khong khoe, met moi, bat an. Ngi ta ang quay tr lai vi quan niem benh tat la roi
loan tac ong len toan the con ngi va nhan ra phan ln benh tat cua con ngi la do loi song;
chang han benh kh phe thung, ung th phoi la do hut thuoc la, x gan do uong qua nhieu ru,
cao huyet ap do cuoc song qua nhieu x tret, beo ph do an qua nhieu thc an Mc Donald, ga
ran Kentucky ... Chnh v the, To chc Y te the gii a nhan manh rang e co sc khoe va khong
benh tat th phai co s thoai mai, khong ch ve the chat ma ca ve tinh than va xa hoi.
I. NH NGHA VA PHAN LOAI GIAI PHAU BENH HOC:

Giai phau benh hoc, con goi la benh hoc, la mon hoc nghien cu ve cac ton thng cua te
bao, mo va cac c quan trong cac trang thai benh ly khac nhau.
Cac ton thng cua c quan quan sat c bang mat tran c goi la cac ton thng ai
the. Ton thng cua mo va te bao ch co the quan sat c di knh hien vi quang hoc hoac
knh hien vi ien t, nen c goi la ton thng vi the va sieu vi the.
Theo truyen thong, mon giai phau benh c chia thanh 2 phan:
* Giai phau benh ai cng, nghien cu ve cac ton thng c ban cua te bao va mo, la c
s chung cho moi loai benh ly cua cac c quan va cac he thong khac nhau. Th du phan ng
viem cap la mot ton thng c ban, c s chung cua viem ruot tha cap, viem phoi thuy...
* Giai phau benh chuyen biet, nghien cu ve cac benh ly rieng biet cua tng c quan hoac
he thong. Th du nh benh ly phoi, benh ly da...
Tuy nhien, muc ch toi hau cua mon giai phau benh khong ch n thuan mo ta ton
thng. Trai lai, thong qua viec phan tch cac hnh thai ton thng, no tm hieu ve nguyen nhan
gay benh, giai thch c che benh sinh va cac roi loan chc nang do ton thng gay ra e gop
phan vao viec chan oan, ieu tr va phong tranh benh. V vay, noi dung c ban cua mon giai
phau benh gom co 4 mat: nguyen nhan gay benh, c che benh sinh, hnh thai ton thng va cac
bieu hien lam sang lien quan vi ton thng.
II. VAT LIEU NGHIEN CU CUA GIAI PHAU BENH HOC
Cac vat lieu nghien cu cua giai phau benh hoc gom nhieu loai:
1. T thiet: la thi the hoac
nhng mau mo c lay t benh
nhan a chet. Giai phau t thi
giup xac nh nguyen nhan gay
chet, kiem nghiem cac chan
oan lam sang nham rut kinh
nghiem e nang cao chat lng
chan oan va ieu tr benh. Cac
nghien cu gan ay tai My cho
thay co en 30% chan oan lam
sang a khong c xac nhan
tren t thiet; chnh v vay ma Hnh 14: T thiet 1 ca tre s sinh t vong v suy ho hap cho thay
cac vien giai phau benh hoac nguyen nhan la do thoat v c hoanh bam sinh ben trai khien da
day va ruot lot vao long ngc gay chen ep
cac sach giai phau benh thng
co e cau Mortui vivos docet (ngi chet day ngi song) (Hnh 14).
2. Sinh thiet: la cac mau mo c lay t ngi song nham phuc vu cho cong tac chan
oan va ieu tr. Cac mau mo co the c lay ra theo nhieu cach (Hnh 15):
* Phau thiet: mot mau mo, mot phan hoac toan bo mot c quan b benh c lay ra
bang phau thuat. Th du: mot phan hach co, toan bo da day, mot thuy giap.
* Sinh thiet qua noi soi: nh ong noi soi, co the dung km kep cat mot mau mo nho
nam sau trong ng tieu hoa, ng ho hap hoac tiet nieu.
* Sinh thiet bang kim: nh cac loai kim ac biet, co the lay c mot mau nho mo gan,
than, mang phoi hoac tuy xng...
Hnh 15: Sinh thiet polyp ai trang qua noi soi (A); sinh thiet choc hut bang kim nho (B)
Mot loai vat lieu khac co the lay ra t ngi song e khao sat la cac loai te bao co trong
dch c the (dch mang phoi, dch mang bung, nc tieu), hoac cac te bao bong troc t nhien t
cac loai bieu mo phu (bieu mo phu am ao - co t cung, bieu mo phe quan). Co the dung mot
so loai dung cu nh que go, cay choi e lam tang so lng te bao bong ra. Ngoai ra, ta cung co
the hut c cac te bao cua bat ky c quan nao trong c the nh vao mot kim nho (c 23-24),
goi la phng phap sinh thiet choc hut bang kim nho (FNAB: fine needle aspiration biopsy)
3. Vat lieu thc nghiem: xay dng tren suc vat cac mo hnh benh tat tng t cac benh ly
cua ngi, e khao sat cac hnh thai ton thng va cac roi loan chc nang kem theo; at c s
cho viec tm hieu nguyen nhan gay benh, c che benh sinh, dien tien cua benh, va th nghiem
cac phng phap ieu tr mi (Hnh 16).
Hnh 16: Gay u nhu tren da chuot bang benzanthracene, gay ung th gan chuot bang nitrosamine
III. PHNG PHAP NGHIEN CU CUA GIAI PHAU BENH

1. Quan sat ai the: nghien cu bang mat tran tat ca nhng ac iem hnh thai (nh kch
thc, mau sac, mat o, g.ii han, vo bao...) cua mot c quan benh ly.
2. Quan sat vi the va sieu vi the: nghien cu cac ton thng cua te bao va mo di knh
hien vi quang hoc hoac knh hien vi ien t. e quan sat c di knh hien vi quang hoc, mau
mo phai c co nh, cat mong 5 m va nhuom mau, thi gian chuan b mat khoang 3-4 ngay.
Quan sat sieu vi the oi hoi mau mo phai c cat mong en 0,1 m, thi gian chuan b mat
hang thang do o t co tnh ng dung trong chan oan giai phau benh thng ngay, chu yeu e
phuc vu cho nghien cu.
Phng phap nhuom thng quy trong cac labo giai phau benh la phng phap nhuom
Hematoxylin-Eosin: te bao se co nhan bat mau tm con bao tng th bat mau hong (Hnh 17A).
Trong mot so trng hp, co the dung them cac phng phap nhuom hoa mo (con goi la nhuom
ac biet) e xac nh mot so cau truc cua te bao va mo da vao ai tnh ac biet cua chung oi
vi mot so loai hoa chat nao o. Th du nhuom Fontana giup phat hien hac to melanin, nhuom
PAS e phat hien glycogen va chat nhay, nhuom Trichrome e thay ro si collagen...(Hnh 17
B,C)
Hnh 17: Niem mac ai trang nhuom Hematoxylin-Eosin (A); nhuom Trichrome, thay ro mang ay bat mau
xanh dng; nhuom PAS (periodic acid-Schiff), giot chat nhay cua te bao ai bat mau hong.
Gan ay, ky thuat hoa mo mien dch a c ap dung rong rai trong cac labo giai phau
benh tai Tp.HCM e ho tr cho chan oan. ay la mot ky thuat nhuom ac biet, s dung phan
ng ket hp khang nguyen - khang the nham phat hien nhng thanh phan cau tao (cac khang
nguyen) co trong te bao va mo. V tr ket hp khang nguyen - khang the se c hien th nh
cac hoa chat. (Hnh 18)
Tuy theo hoa chat hien th, phan biet hai phng phap nhuom hoa mo mien dch chnh:
* Mien dch huynh quang:
Khang the c gan vi chat phat huynh quang. Neu co phan ng ket hp khang nguyen -
khang the (ngha la co s hien dien cua khang nguyen can tm trong mau mo), phc hp khang
nguyen-khang the se phat quang khi c kch thch bi tia cc tm, quan sat di knh hien vi
huynh quang.
Chat phat huynh quang co the c gan trc tiep vao khang the ac hieu, goi la phng
phap mien dch huynh quang trc tiep; hoac gan vao khang the th hai ac hieu vi khang the
th nhat, goi la mien dch huynh quang gian tiep.
Mien dch huynh quang c s dung chu yeu trong chan oan cac benh ly cau than va
mot so benh ly cua da (Hnh 19A).
Hnh 18: Mien dch huynh quang va mien dch men, trc tiep (A) va gian tiep (B)
* Mien dch men:

Khang the c gan vi men (enzyme). Khi cho them chat hien mau vao mau mo, men
lam ket tua chat mau (thng la mau nau) tai v tr phc hp khang nguyen-khang the, nh o
thay c di knh hien vi quang hoc.
Cung giong nh vi chat phat huynh quang, neu men c gan trc tiep vao khang the
th nhat ac hieu vi khang nguyen, goi la phng phap mien dch men trc tiep. Khi men c
gan vao khang the th hai ac hieu vi khang the th nhat, goi la mien dch men gian tiep.
- Mien dch men c s dung nhieu trong chan oan cac benh ly u bu, giup xac nh
nguon goc cua cac khoi u co o biet hoa qua kem hoac khong biet hoa e phan biet gia
carcinom, sarcom hay limphom (Hnh 19B). Trong mot so trng hp, chang han oi vi ung th
vu, mien dch men con co gia tr anh gia tien lng va ap ng ieu tr (anh gia tnh trang thu
the noi tiet estrogen, thu the Her-2/neu).
Hnh 19: Hoa mo mien dch huynh quang, dung khang the huynh quanh chong IgA cho thay co s lang ong
cua IgA vung gian mao mach trong benh than IgA (A). Mot u kem biet hoa cau tao bi te bao hnh thoi
trong giong nh mot sarcom (B1), nhuom hoa mo mien dch men vi khang the chong cytokeratin cho thay
te bao u bat mau nau (B2), chng to ay la mot carcinom ch khong phai la sarcom.
Ngoai ra, cac ky thuat tien tien ng dung sinh hoc phan t nh ky thuat lai ghep tai cho
phat huynh quang (fluorescent in situ hybridization, FISH), phan ng chuoi polymerase
(polymerase chain reaction, PCR), v.v. cung ang tng bc c a vao s dung trong labo
giai phau benh nham phuc vu cho cong tac chan oan; cac ky thuat nay tuy co o chnh xac
cao nhng chi ph cung cao khong kem! (Hnh 20).
Hnh 20: Ky thuat FISH cho thay co s khuyech ai gen HER-2/neu len gap 3 lan
(bieu hien bang cac om o trong nhan) cac te bao carcinom tuyen vu
(B) so vi te bao bieu mo ong tuyen vu bnh thng (A).
3. oi chieu lam sang - giai phau benh

La hoat ong phoi hp thng xuyen can phai co gia cac bac s lam sang, bac s giai
phau benh va cac bac s thuoc cac khoa can lam sang khac nh X-quang, sieu am; e co c
chan oan chnh xac va ieu tr ung an, cung nh e rut kinh nghiem oi vi cac trng hp
benh nhan t vong.
Ton Thng C Ban cua Te bao va Mo 11
TON THNG C BAN CUA TE BAO VA MO

Muc tieu:
1. Mo ta va phan tch 5 loai ap ng thch nghi.
2. Mo ta va phan tch 4 loai ong noi bao.
3. Mo ta va phan tch 4 loai lang ong ngoai bao.
4. Mo ta cac ac iem hnh thai cua hoai t te bao va t huy te bao. .
5. Mo ta va phan tch cac hnh thai mo hoc cua hoai t.
Giai phau benh ai cng nghien cu ve cac ton thng c ban, la ton thng chung cua
moi loai benh ly cac c quan va he thong khac nhau.
Ton thng c ban la cac bien oi hnh thai cua te bao va mo gay ra bi cac nguyen nhan
benh ly hoac sinh ly, gom co 7 loai la: cac ap ng thch nghi, ong noi bao, lang ong ngoai
bao, hoai t, viem, u, ton thng huyet quan huyet do roi loan tuan hoan.
CAC AP NG THCH NGHI

La cac bien oi hnh thai cua te bao va mo nham thch ng vi moi trng xung quanh a
b thay oi. Co 5 loai ap ng thch nghi sau:
1. PH AI (hypertrophy)
La hien tng tang kch thc te bao. Te bao tang kch thc bi v co s tang tong hp
tat ca cac thanh phan cau tao cua no. Nhieu te bao ph ai se dan en s ph ai cua 1 mo, 1
c quan. Nguyen nhan gay ph ai thng la do co mot yeu cau cao hn ve mat chc nang oi
vi te bao va mo hoac do co s kch thch cua mot hormon ac hieu. Ph ai co lien quan mat
thiet vi tang san va ca 2 hien tng nay thng xay ra ong thi vi nhau. Ph ai c phan
thanh 2 loai: ph ai sinh ly va ph ai benh ly.
a/ Ph ai sinh ly:
Khi mang thai, te bao c trn t cung c estrogen kch thch se ph ai gap 10 lan bnh
thng. Estrogen gan len cac thu the tng ng co trong bao tng te bao c trn, i vao trong
nhan va tng tac vi ADN, kch thch s tong hp cac ARNm; ket qua lam tang so lng
protein cua te bao c trn va lam tang kch thc te bao. cac van ong vien, cac te bao c
van ph ai e thch nghi vi yeu cau tang cao ve chc nang co duoi cua c trong qua trnh tap
luyen (Hnh 1).
Hnh 1: Ph ai sinh ly t cung khi mang thai (A); te bao c trn bnh thng (B); te bao c trn ph ai (C).
b/ Ph ai benh ly:
Trong benh cao huyet ap hoac hep van ong mach chu, tam that trai cua tim phai co bop
manh hn e thang c s gia tang lc can trong ong mach; e thch nghi te bao c tim se
ph ai, lam vach tim day len va lam tang trong lng qua tim (Hnh 2).
Hnh 2: Ph ai benh ly that trai do cao huyet ap (A); te bao c tim bnh thng (B); te bao c tim ph ai (C).
2. TANG SAN (hyperplasia)

La hien tng tang so lng te bao bang hoat ong phan bao. Nh vay, ch nhng te bao
con gi c kha nang phan bao mi co the tang san. Tang san cung c phan biet thanh 2
loai: tang san sinh ly va tang san benh ly.
a/ Tang san sinh ly:

Khi mang thai, cac te bao tuyen vu va tang san va ph ai e chuan b cho hoat ong
tiet sa, tng t nh vay oi vi cac te bao c trn cua t cung. gan, neu mot phan gan b
cat bo, phan con lai se tang san nham bu ap lai so te bao gan a mat, con goi la tang san bu
tr (Hnh 3).
Hnh 3: Anh chup CT mot ngi trc khi hien tang thuy phai gan (A); ch 1 tuan sau phau thuat, thuy trai
gan a to han ra do hoat ong tang san bu tr (B). Vi the mo gan bnh thng t thay hnh anh phan bao
(C); con mo gan tang san bu tr th co t le phan bao cao (D).
b/ Tang san benh ly:
Hau het eu do s kch thch qua mc cua mot hormon ac hieu. Tang san benh ly khac
vi s tang sinh cua cac te bao u cho no se bien mat khi khong con kch thch cua hormon.
Th du nh tnh trang tang san noi mac t cung gay ra bi s gia tang estrogen, khi lng
estrogen tr ve bnh thng, tnh trang tang san noi mac se bien mat. Tuy nhien, tang san benh
ly van la mot manh at mau m cho s phat trien cua ung th, th du tnh trang tang san noi
mac t cung khong kiem soat c co the dan en carcinom tuyen noi mac (Hnh 4).
Tang san co the dien ra ong eu hoac khong ong eu cho tat ca cac te bao trong cung
mot mo. Trng hp tang san khong ong eu, ch xay ra mot so nhom te bao, se tao thanh
cac cuc tang san; do o kieu tang san nay c goi la tang san dang cuc, thng thay tuyen
tien liet, tuyen giap, tuyen vu, lp c trn than t cung.
Hnh 4: Noi mac t cung: bnh thng (A); tang san benh ly (B); carcinom tuyen noi mac (C)
3. TEO ET (atrophy)
La hien tng giam kch thc va the tch te bao do cac thanh phan cau tao cua no eu b
giam so lng. Di KHVT, ngi ta thay co s gia tang so lng tui t thc va khong bao t
thc trong bao tng. Mo hoac c quan se teo nho lai khi co nhieu te bao b teo et. Cac
nguyen nhan gay teo et te bao gom co: s giam yeu cau chc nang oi vi te bao va mo, mat
phan bo than kinh, giam ti mau nuoi, suy dinh dng, mat s kch thch cua hormon ac hieu,
s gia nua. Teo et c phan thanh 2 loai: teo et sinh ly va teo et benh ly.
a/ Teo et sinh ly:
- T cung nho lai sau sinh.
- Cac c van ngi gia b teo lai do s giam hoat ong.
- Cac tuyen sinh duc cua ngi gia b teo lai do mat cac kch thch hormon.
b/ Teo et benh ly:
- Teo c do benh bai liet lam ton thng cac nron van ong (Hnh 5).
- Teo c do chi b gay xng phai bo bot bat ong.
- S teo dan bo nao do benh x va ong mach lam giam lng mau nuoi.
Can phan biet s teo et te bao vi hien tng thoai trien (involution) cua mot so c quan,
xay ra trong qua trnh phat trien t nhien cua c the. Trong hien tng nay, co s giam so lng
te bao bang c che t huy te bao (apoptosis), ket qua c quan b teo nho lai; th du nh s thoai
trien cua tuyen c tuoi thieu nien. Trong s teo nho cac c quan sinh duc ngi gia, thc ra
co s phoi hp cua ca 2 hien tng: teo et te bao va thoai trien.
Hnh 5: Teo c cang chan phai do benh bai liet (A); Te bao c van bnh thng (B); Te bao c van teo et.
4. CHUYEN SAN (metaplasia)

oi vi mot so loai thay oi cua moi trng xung quanh, te bao ch co the thch nghi tot
bang cach thay oi hng biet hoa, goi la chuyen san. ay la hien tng chuyen dang t 1 loai
mo a biet hoa thanh 1 mo biet hoa khac nhng van cung loai (cung la bieu mo hay trung mo).
Chuyen san la 1 ton thng co tnh kha hoi.
Th du:
- ngi nghien thuoc, bieu mo tru gia tang cua kh phe quan thch nghi vi s kch
thch keo dai cua khoi thuoc bang cach chuyen dang thanh bieu mo lat tang, goi la chuyen san
gai cua bieu mo ho hap.
- co t cung cua ngi phu n trng thanh, phan bieu mo tru n tiet nhay cua co
trong thng b lon ra ngoai, goi la tnh trang lo tuyen co t cung; e thch nghi vi moi trng
acid trong am ao, bieu mo tru n co trong se chuyen thanh bieu mo lat tang giong bieu mo
co ngoai co t cung, goi la hien tng chuyen san gai. (Hnh 6)
Hnh 6: Lo tuyen co trong co trong co t cung ( mui ten, A); Bieu mo tru n co trong bnh thng (B); bat
au chuyen san thanh 2 lp (C); nhieu lp (D); cuoi cung tr nen bieu mo lat tang giong giong co ngoai (E).
- Bieu mo chuyen tiep cua bang quang chuyen san thanh bieu mo lat tang do b kch thch
keo dai bi soi bang quang hoac nhiem trung.
- Bieu mo lat tang oan di thc quan chuyen thanh bieu mo tru n tiet nhay e
thch ng vi axit co trong dch v trao ngc len thc quan.
- Bieu mo tru n tiet nhay cua be mat niem mac da day chuyen thanh bieu mo co te bao
hnh ai tiet nhay giong bieu mo ruot, do viem man tnh
- Mo si co the chuyen san thanh mo sun hoac mo xng sau 1 chan thng (Hnh 7).
Hnh 7: Mo si sau chan thng (A); cac be xng (mui ten) do mo si chuyen san tao ra.
5. NGHCH SAN (dysplasia)

Nghch san la 1 roi loan cua s tang sinh te bao, dan en s thay oi hnh dang, kch
thc cua te bao cung nh cach to chc sap xep cua chung trong mot mo. Nghch san thc
chat khong phai la 1 ap ng thch nghi, nhng do co moi lien quan mat thiet vi tang san nen
van c e cap tai ay.
Nghch san xay ra chu yeu cac bieu mo (thng la 1 bieu mo a b chuyen san) do tac
ong keo dai cua 1 kch thch. Cac te bao nghch san co kch thc to nho khong eu, nhan
tang sac va cung co kch thc to nho khong eu, t le nhan/ bao tng tang, t le phan bao tang
nhng khong co phan bao bat thng, nh hng sap xep cua cac lp te bao trong mo b roi
loan. oi vi bieu mo lat tang, tuy theo cac hnh anh bien oi noi tren con gii han 1/3 di,
1/3 gia hoac a len en 1/3 tren cua chieu day bieu mo, phan biet ra 3 mc o nghch san:
nhe, va va nang. Khi hnh anh bien oi a chiem toan bo chieu day bieu mo, ke ca lp be mat
th ton thng khi o c goi la carcinom tai cho. Nh vay nghch san c xem la ton thng
tien ung th v nghch san nang co the chuyen thanh ung th; tuy nhien no van con la mot ton
thng kha hoi v bieu mo nghch san mc o nhe va va co the tr lai bnh thng khi khong
con tac nhan kch thch (Hnh 8).
Hnh 8: Bieu mo lat tang bnh thng (A); b nghch san nhe (B); nghch san va (C); nghch san nang (D).
Th du trong trng hp co t cung b viem nhiem keo dai, bieu mo tru n cua co trong
chuyen san thanh bieu mo lat tang. Neu viem nhiem tiep tuc gia tang, bieu mo lat tang nay co
the b nghch san t nhe en nang; neu nghch san nang keo dai ma khong c ieu tr th co
the chuyen thanh carcinom tai cho va tiep sau o la carcinom te bao gai xam lan.
ONG NOI BAO (intracellular accumulation)

La hien tng ong ben trong te bao 1 san pham chuyen hoa bnh thng hoac bat
thng. Tuy theo mc o ong, hoat ong cua te bao co the b roi loan t t en nhieu hoac
tram trong en mc gay chet te bao.
1. ONG NC
La hien tng ong nc trong te bao, chu yeu gap te bao ong than, gan, tim.
Nguyen nhan: cac tnh trang thieu mau, thieu oxy, ngo oc (Chloroform, tetrachlorur
carbon...), nhiem trung... lam giam s san xuat ATP tai ty the. Do thieu hut ATP, hoat ong cua
bm Na+/ K+ - ATPase mang te bao b roi loan, dan en ong natri trong te bao, ket qua
nc b keo vao lam trng gian cac bao quan va toan bo te bao.
Hnh thai ton thng:
- ai the: cac tang nc b trng to tang trong lng, vo boc cang, mau sac lt lat.
- Vi the: tuy theo mc o ong nc, co the thay hnh anh:
* Trng uc te bao (cloudy swelling): do nc mc o trung bnh, te bao trng to, bao
tng dang hat, bat mau kem, nhan con gia te bao. giai oan nay, ton thng con kha hoi.
* Thoai hoa nc (hydropic degeneration): do nc tram trong, te bao trng to, bao
tng b choan bi cac khong bao ln khong mau ma ban chat la cac tui li noi bao b trng
to, nhan b ay lech ra ngoai vi. Te bao co the v, chet (Hnh 9).
Hnh 9: Te bao gan bnh thng (A); Trng uc te bao gan (B); Thoai hoa nc te bao gan
2. ONG LIPID
a/ ong triglycerid ( ong m):

Thng gap gan v chuyen hoa m c thc hien chu yeu tai ay, cung co the gap
cac tang khac nh tim, than, c.
Nguyen nhan gay ong m a dang va khac nhau tuy c quan. Gan thng b ong
m chu yeu la do ngo oc ru, hoac do suy dinh dng. Tim b ong m do thieu oxy man,
do oc to cua vi khuan nh trong trong benh viem c tim do vi khuan benh bach hau.
Hnh thai ton thng:
- ai the: tang b ong m to ra, mau vang.
- Vi the: tuy mc o ong, trong bao tng cha nhieu khong bao nho khong mau hoac
mot khong bao ln duy nhat, ay nhan lech ra ngoai vi. Neu ong qua nang, te bao b hoai t
(Hnh 10).
Hnh 10: Gan bnh thng (A); Gan ong m (B); te bao gan cha mot giot m ln trong
bao tng lam nhan b ay lech (C); giot m bat mau o vi pham nhuom Oil Red O (D)
Can phan biet ton thng ong m vi s xam nhap m vao mo em (stromal
infiltration of fat) tc la s xam nhap cua cac te bao m trng thanh vao trong mo lien ket cua
cac tang (thng nhat la tim va tuy tang), xay ra trong qua trnh lao hoa. S xam nhap nay
khong gay anh hng g en hoat ong bnh thng cua tang b xam nhap.
b/ ong cholesterol va cholesterol ester hoa:
Bnh thng, cholesterol c van chuyen t gan en te bao se c s dung het e tong
hp cac cau truc mang nen khong b lai trong bao tng. Trong mot so benh ly nh benh x
va ong mach, benh tang cholesterol mau co tnh chat gia nh; cholesterol va cholesterol
ester hoa b ong trong cac ai thc bao di dang nhng khong bao rat nho, lam cho ai
thc bao co hnh anh bot bao (foam cell). Cac bot bao nay co the tap trung nhieu trong mo lien
ket cua da, tao thanh cac am sui mem mau vang goi la u vang (xanthoma) (Hnh 11).
Hnh 11: U vang m mat tren (A); Cac bot bao ong cholesterol
c/ ong lipid phc tap:
Gap trong 1 so roi loan chuyen hoa bam sinh goi chung la cac benh tch tieu the
(lysosomal storage disease); lipid b ong trong cac tieu the do tieu the b thieu hut enzym
thuy phan tng ng.
Th du: trong benh GAUCHER, co s thieu hut enzym glucocerebrosidase lam
glucocerebroside b lai trong tieu the cua cac ai thc bao. Cac ai thc bao nay con c goi
la te bao Gaucher, co kch thc ln (100mcm), bao tng co dang si.
Trong benh NIEMANN - PICK, co s thieu hut enzym sphingomyelinase lam sphingomyelin
b lai trong tieu the cua cac ai thc bao. Cac ai thc bao nay co kch thc ln, co dang te
bao bot do bao tng cha ay nhng khong bao nho.
3. ONG GLUCID
a/ ong glycogen:
Gap trong cac roi loan chuyen hoa glucoz nh benh tieu ng hoac cac benh tch
glycogen (glycogen storage disease).
Trong benh tieu ng, glucoz thoat vao ong than gan se c cac te bao bieu mo ong
than co tai hap thu cho het. Ket qua la glucoz b ong trong bao tng di dang glycogen,
tao thanh cac khong bao nho kho thay, nhieu khi phai nhuom ac biet (PAS, Carmin de Best )
mi phat hien c (Hnh 12).
Hnh 12: ong glycogen trong te bao bieu mo ong than kho thay vi nhuom thong thng (A); thay ro khi
nhuom vi pham nhuom Carmin de Best
Trong benh tch glycogen (benh Von Gierke, benh Mc Ardle, benh Pompe, v.v.), co s
thieu hut mot trong cac enzym lien quan en qua trnh tong hp hoac giang hoa glycogen, ket
qua la glycogen b lai trong bao tng hoac trong tieu the cua cac te bao gan, than, c tim...
lam tang kch thc va roi loan hoat ong cac c quan.
b/ ong mucopolysaccharide:
Benh tch mucopolysaccharide (mucopolysaccharidoses) la mot nhom benh roi loan
chuyen hoa bam sinh gay ra s thieu hut 1 trong cac enzym can cho s giang hoa cac
mucopolysaccharide nh heparan sulfate, keratan sulfate, chondroitin sulfate, dermatan sulfate.
Ket qua la cac mucopolysaccharide b lai trong tieu the cua cac ai thc bao, te bao c trn,
te bao noi mo, nguyen bao si trong khap c the.
4. ONG PROTEIN
ac trng bi s xuat hien trong bao tng cac the vui hnh tron ong nhat vo nh hnh,
trong nh knh, bat mau pham nhuom acid, goi la cac the vui hyalin (Hnh 13).
3 c che gay ong protein noi bao:
- Nhap bao qua mc: th du trong cac benh cau than lam thoat protein huyet tng vao
dch loc cau than, cac te bao ong than co gang tai hap thu toi a, ket qua bao tng cha nhieu
the vui hyalin trong te bao.
- Xuat bao qua cham: th du trong benh a u tuy, cac tng bao co trong bao tng cac
the vui hyalin hnh tron (the RUSSEL), tng ng vi li noi bao cha ay globulin mien dch
ma le ra phai c xuat bao.
- Ton thng bo xng te bao: th du trong ngo oc ru, te bao gan cha nhng the vui
hyalin (the MALLORY) do cac sieu si trung gian cytokeratin ket tu vi ubiquitin nhau tao thanh.
Hnh 13: Bieu mo ong than bnh thng (A); Bieu mo ong the vui hyalin (B)
5. ONG SAC TO
Sac to b ong trong te bao co the co nguon goc ngoai sinh hoac noi sinh.
a/ Ngoai sinh: th du ong bui than trong cac ai thc bao phe nang (cong nhan mo
than), ong mc xam trong cac ai thc bao cua lp b (vet xam). S ong cac sac to nay
khong kch thch phan ng viem.
b/ Noi sinh: la cac sac to do chnh te bao tong hp, th du nh :
Hnh 14: Te bao gan ong cac sac to eu co mau nau khi nhuom thong thng (A, C, E); nhuom
ac biet e phan biet la lipofuscin (bat mau en vi Fontana, B), hemosiderin (mau xanh dng vi
Perls, D) va bilirubin (mau xanh la vi Fouchet, F)
- LIPOFUSCIN: ong trong te bao gan, tim cua ngi gia hoac ngi b oi an lau ngay.
Di KHVT, cac hat lipofuscine tng ng vi cac the can ba cua khong bao t thc.
- MELANIN: la mot sac to bnh thng co trong cac hac bao lp ay cua bieu b. Trong
cac bu lanh hoac ac xuat phat t hac bao, co s ong sac to nay ben trong bao tng.
- HEMOSIDERIN: sac to cha sat c tao thanh do s giang hoa cac phan t hemoglobin
cua hong cau gia, bnh thng van thay trong bao tng cua cac ai thc bao lach.
Hemosiderin b ong trong cac ai thc bao phe nang nhng ngi suy tim, trong cac te bao
nhu mo gan, than, tim nhng ngi b benh sat (hemosiderosis).
- BILIRUBINE: cung c tao thanh t s giang hoa hemoglobine, b ong trong te bao
gan do cac benh ly gay tac mat.
Cac sac to tren eu bat mau nau khi nhuom thong thng (Hematoxylin-Eosin); e phan
biet, co the dung cac phng phap nhuom ac biet nh Perls (nhuom xanh dng hemosiderin),
Fouchet (nhuom xanh la cay bilirubin), Fontana (nhuom en melanin va lipofuscin), PAS (nhuom
o lipofuscin) (Hnh 14).
LANG ONG NGOAI BAO

ac trng bi s hien dien qua mc 1 chat hu c hoac vo c trong khoang gian bao.
1. LANG ONG CHOLESTEROL

Xay ra khi co 1 so lng ln
cholesterol c giai phong vao moi
trng ngoai bao, th du nh s giai
phong cholesterol t mang cac hong
cau b v trong khoi mau tu.
Cholesterol co the ket tinh thanh cac
tinh the hnh kim va sau o b thc bao
bi cac ai thc bao (Hnh 15).
Hnh 15: Cholesterol lang ong ngoai bao di
dang tinh the hnh kim
2. LANG ONG PROTEIN

Phan biet 3 loai (Hnh 16):
a/ Lang ong hyalin: co dang mot chat vo nh hnh, trong nh knh va a pham nhuom
acid. Co the gap trong thanh ong mach ngi ln tuoi, trong to chc lien ket cua cac seo cu,
trong cac o viem man tnh. Cau tao cua hyalin rat phc tap, gom cac thanh phan protein cua
huyet tng t trong long mach tham ra nh fibrin, globulin mien dch loai IgM, IgG, cac
lipoprotein va bo the. ang chu y la khong co phan ng viem i kem s lang ong hyalin nay.
b/ Lang ong chat dang fibrin (fibrinoid substances): di dang si, rat a pham nhuom
acid. Gap trong thanh tieu ong mach cua ngi b cao huyet ap ac tnh, trong mo lien ket cua
ngi mac benh tao keo. Luon co phan ng viem i kem s lang ong chat dang fibrin. Cau tao
cua chat dang fibrin cung tng t nh chat hyalin nhng giau fibrin hn.
c/ Lang ong chat dang tinh bot (amyloid substances): co dang cac cuon bong gon, a
pham nhuom acid. Gap trong thanh tieu ong mach, doc theo thanh cac mao mach dang xoang
gan va lach cua ngi mac benh viem nhiem man tnh, u tuy (myelome); cau tao hoa hoc chu
yeu la cac globulin mien dch. Trong benh ung th tuyen giap dang tuy, cung co s lang ong
ngoai bao chat dang tinh bot, nhng cau tao hoa hoc lai la chat calcitonin do te bao ung th tiet
ra. Khi nhuom thong thng, chat dang tinh bot trong giong nh hyalin. e phan biet, cho
nhuom o congo (red congo), chat dang tinh bot bat mau cam nhng se oi sang mau vang
xanh khi quan sat bang knh hien vi phan cc.
Hnh 16: Lang ong hyalin trong thanh ong mach (A); lang ong chat dang fibrin trong thanh mach, kem
phan ng viem (B); Chat dang tinh bot bat mau cam khi nhuom o congo (C), oi sang vang xanh di anh
sang phan cc (D).
3. LANG ONG CALCI

Phan biet 2 loai:
a/ Calci hoa nghch dng: calci b lang ong trong mo chet (o hoai t ba au, o mau tu,
mang x va thanh ong mach, ung th tuyen giap dang nhu...); tao thanh nhng am vo nh
hnh, dang hat, bat mau kiem hoac nhng cau truc nh the cat (psammoma bodies) (Hnh 17).
Hnh 17: cac am calci vo nh hnh bat mau kiem, trong o mau tu ( mui ten, A); hoac tao thanh the cat
trong ung th tuyen giap dang nhu (mui ten, B).
b/ Calci hoa di can: calci b lang ong trong cac mo song (chu yeu la thanh mach mau,
nhu mo than, gan, niem mac da day) do tnh trang tang calci mau (trong cac benh nh cng
tuyen can giap, u xng co huy xng...). Hnh anh vi the cua cac am calci cung tng t
trong calci hoa nghch dng.
4. LANG ONG URAT
Hnh 18: Not tophi khp ngon tay (A); tren vi the, am urat lang ong (*) c bao quanh bi cac te bao
viem.
Gap trong benh gut, la mot nhom benh ly co ac iem chung la tnh trang roi loan chuyen
hoa purin, dan en tnh s tang cao acid uric trong mau (> 7mg%). Acid uric se b lang ong
trong nhieu c quan khac nhau nh khp, than, kch thch manh phan ng viem gay ra viem
khp man tnh, viem than. S lang ong urat trong mo quanh khp tao thanh cac not tophi, cau
tao gom mot am tinh the urat co dang si (co hnh kim di knh hien vi phan cc), c bao
quanh bi cac te bao viem nh ai thc bao, lympho bao va ai bao an d vat (Hnh 18).
S CHET TE BAO (Cell death)

Te bao chet khi b cac thng ton bat kha hoi do tac ong cua cac yeu to oc hai t moi
trng ben ngoai, hoac do ban than te bao a tr nen khong con can thiet oi vi mo c the.
Da vao s khac biet ve ac iem hnh thai, nguyen nhan va c che phat sinh, phan biet 2 kieu
chet te bao la: hoai t te bao va t huy te bao (Hnh 19) .
Hnh 19: Hai kieu chet te bao: hoai t te bao va t huy te bao
A. HOAI T TE BAO (necrosis):
La toan bo cac bien oi hnh thai xay ra khi te bao chet do cac nguyen nhan benh ly. Cac
bien oi sieu cau truc xuat hien sm, ch t phut sau khi te bao chet; nhng phai sau vai tieng
ong ho mi co the quan sat c cac bien oi vi the.
Trong hien tng hoai t te bao, te bao thng chet vi so lng ln, anh hng en
chc nang cua mo va luon kch thch theo phan ng viem.
1. AC IEM HNH THAI:

a/ Bien oi nhan:
Gom 3 bien oi noi tiep nhau :
- Nhan ong (pyknosis): nhan von cuc nho lai, bat mau kiem am do chat nhiem sac b co
ac.
- Nhan v (karyorrhexis): do chat nhiem sac co ac thanh nhieu khoi .
- Nhan tan (karyolysis): chat nhiem sac b hoa tan dan, nhan ch con la 1 bong m nhat
va bien mat .
Trong moi te bao hoai t, bien oi nhan xuat hien theo ung th t tren, nhng ca 3 hnh
anh co the cung hien dien trong nhng te bao khac nhau cua 1 mau mo hoai t (Hnh 20).
Hnh 20: Cac bien oi nhan cua te bao hoai t, so sanh vi te bao bnh thng: nhan ong te bao ao
Langerhans tuy tang (A), nhan v te bao gan (B), nhan tan te bao ong than (C).
b/ Bien oi bao tng:

Xuat hien trc bien oi nhan, cung gom 3 bien oi noi tiep nhau:
- Giam tnh bat mau kiem: thay ro nhat nhng te bao co cha nhieu ribosome trong
bao tng. C che cua bien oi nay la do s giai trung hp ARN lam phan ra cac ribosome.
- Tang tnh bat mau acid: do protein bao tng b bien chat, mat i cac goc carboxyl.
- Xoa m cac cau truc trong bao tng: do s phan ra cac bao quan, th du nh mat hnh
anh cac vi si c trong te bao c van, mat cac vi nhung mao be mat cc nh te bao bieu mo
ong than,.. ket qua bao tng bat mau trong eu hoac lo cho do cha nhieu khong bao (Hnh
21).
Hnh 21: Te bao gan bnh thng (A); Te bao gan hoai t, bao tng mat tnh bat mau kiem (B); bao tng
te bao c van hoai t, tang tnh bat mau acid, cac cau truc trong bao tng b xoa (mui ten, C)
c/ Bien oi mang te bao:

Mang cua te bao va cac bao quan mat tnh tham chon loc, lam the tch te bao tang va
trng to cac bao quan.
Hnh 22: Te bao bieu mo ong than gan bnh thng, co vi nhung mao cc nh (*) (A); Khi b hoai t, mang
te bao tao ra cac bong nho (mui ten), vi nhung mao bien mat, nhan nho lai va co ac, bao tng co cac ty
the phong to va nhieu khong bao; Te bao hoai t no tung, giai phong cac thanh phan cau tao ra moi
trng ben ngoai (C). Te bao gan bnh thng, bao tng co li noi bao hat phat trien phong phu va nhieu
ti the (D); Khi b hoai t, li noi bao hat phong to va mat cac hat ribosom tren be mat (*), ty the phong to
(mui ten), nhan v vun (E).
Di KHVT, mang te bao hoai t phong len thanh cac bong nho tren be mat, cac cau
truc chuyen biet cc nh (neu co) nh vi nhung mao hoac long chuyen te bao cung b phong
len va bien mat. Nhan te bao co ac va tan dan. Li noi bao hat phong to, cac ribosom bam
ngoai be mat bong vao trong dch bao tng, ty the va tieu the cung b phong len va nt v; bo
xng te bao sup o tao thanh cac am ket tua trong bao tng. Hnh anh cuoi cung la toan bo
te bao b no tung (Hnh 22).
2. NGUYEN NHAN VA C CHE GAY HOAI T TE BAO
Hoai t te bao ch xay ra trong cac tnh trang benh ly, do cac nguyen nhan sau:
- Thieu oxy: do suy tuan hoan, thieu mau cuc bo,...
- Cac tac nhan vat ly: nh chan thng c hoc, cac bc xa ion hoa, nhiet o, ien the...
- Tac nhan hoa hoc: cac oc chat nh cyanur, acid, baz; hoac ngay ca cac chat co ve vo
hai nh glucoz, muoi, neu tac ong vao te bao vi nong o qua cao.
- Tac nhan nhiem trung: nh vi khuan, ky sinh trung, virut, nam moc.
- ap ng mien dch bat thng nh trong cac benh ly qua man hoac t mien.
C che gay hoai t te bao co the khac biet nhieu t tuy tng loai nguyen nhan, lieu lng
va thi gian tac ong cua no, va tuy theo loai te bao nao trong c the ang chu tac ong; nhng
nhn chung, chung eu c thc hien thong qua cac roi loan sinh hoa rieng le hay phoi hp,
xay ra tren ty the, mang te bao va mang cac bao quan (Hnh 23).
Hnh 23: C che gay hoai t te bao
- Ty the b ton thng khien mang ty the khong con gi c tnh tham chon loc; phan
ng oxy hoa-phosphoryl hoa b nh tre dan en s thieu hut ATP. Te bao phai s dung con
ng ng phan k kh e san xuat ATP vi he qua la nguon d tr glycogen trong bao tng
b can kiet kem ong acid lactic noi bao; pH noi bao giam lam chat nhiem sac trong nhan b
co ac lai (hnh anh nhan ong).
- Mang te bao khong con gi c tnh tham chon loc do bm Na+/K+- ATPase ngng
hoat ong v thieu hut ATP; ion Na+ va nc t ngoai ua vao trong lam tang the tch te bao. Do
pH noi bao giam, bm Na+/H+ c kch hoat e ay bt H+ ra ngoai nhng lai tang them Na+
noi bao. S tang Na+ noi bao se kch hoat bm Na+/Ca2+ e ay Na+ ra ngoai nhng lai lam
tang Ca2+ noi bao. Ca2+ noi bao tang se hoat hoa hang loat enzym co trong bao tng, gay ra
cac ton thng bat kha hoi nhan, mang te bao va cac bao quan, th du:
* Phospholipase phan huy cac phospholipid mang.
* Protease lam v mang cua te bao va cac bao quan, lam sup o bo xng te bao.
* ATPase, gay thieu hut ATP tram trong hn.
* Endonuclease, cat khuc ADN trong nhan (hnh anh nhan v).
- Tieu the b v mang bao se giai phong vao trong bao tng cac enzym thuy phan rat
manh, sau khi c hoat hoa bi pH acid noi bao, co kha nang phan huy moi thanh phan cau
tao cua te bao, th du:
* Desoxyribonuclease (DNase): phan huy ADN (hnh anh nhan tan dan).
* Ribonuclease (RNase): phan huy ribosome (hnh anh bao tng giam tnh bat
mau kiem).
* Protease: giang hoa cac protein noi bao, lam mat i cac goc carboxyl (hnh anh
tang tnh bat mau acid).
* Enzym tieu the pha v cac bao quan khac (hnh anh xoa m cac cau truc trong
bao tng.
Ket qua cuoi cung, te bao hoai t b no tung, giai phong ra ben ngoai cac thanh phan
noi bao, trong o co nhng chat trung gian hoa hoc manh, thu hut cac bach cau va ai thc
bao.
3. HIEN TNG T TIEU VA D TIEU (autolysis - heterolysis)
Trong c the song, cac te bao hoai t c loai bo theo 2 c che:
- T tieu: cac te bao hoai t b phan ra va loai bo bi enzym tieu the cua chnh mnh, th
du nh cac te bao tuy tang hoai t se b phan ra va loai bo bi chnh cac enzym tieu the cua
chung.
- D tieu: te bao hoai t b loai bo bang enzym tieu the cua cac te bao khac, th du nh s
tieu huy cac te bao c b hoai t nh vao hoat ong cua cac bach cau a nhan trung tnh, ai
thc bao (Hnh 24).
Hnh 24: Te bao tuyen tuy ngoai tiet hoai t (A), c loai bo bang c che t tieu (B); te bao c van hoai t
B. T HUY TE BAO (apoptosis):

Te bao chet bang cach khi ong chng trnh t huy, theo o mot loat cac enzym trong
te bao se c hoat hoa e phan cat te bao thanh nhng manh nho goi la the t huy.
Trong hien tng t huy te bao, te bao chet rieng le, so lng t, khong anh hng en
chc nang cua mo va khong kch thch phan ng viem.
1. AC IEM HNH THAI:
Te bao t huy co the tch giam, kch thc thu nho lai. Nhan tang sac bat mau kiem am
do chat nhiem sac co ac, co the thay nhan a b phan cat thanh nhieu manh nho. Bao tng
am ac do cac bao quan ben trong b len chat. Te bao t huy cuoi cung se uc cat thanh
cac the t huy; moi the t huy la 1 tui mang cha bao tng, cac bao quan va cac manh nhan,
se c cac ai thc bao an ngay lap tc (Hnh 25).
Hnh 25: Te bao bieu mo ruot t huy (mui ten) co kch thc thu nho, nhan am mau, bao tng am ac
(A); Trong trung tam mam cua 1 nang limpho th cap, limpho bao t huy phan thanh cac the t huy (mui
ten) va a c ai thc bao an va a vao trong bao tng.
Di KHVT, chat nhiem sac co ac thanh nhieu khoi bam ngay di mang nhan. Mang
te bao co the tao ra cac bong nho tren be mat nhng cau truc cua mang va cac bao quan van
con nguyen ven (Hnh 26).
Hnh 26: So vi limpho bao bnh thng tren, limpho bao t huy di tao ra cac bong nho tren be mat
(A). Nhan cac limpho bao t huy co chat nhiem sac co ac di mang nhan, a tach ra thanh nhieu manh
(*) (B). The t huy (mui ten) cua limpho bao chet nam trong khong bao tieu hoa cua 1 ai thc bao (C).
2. NGUYEN NHAN VA C CHE GAY T HUY TE BAO

Khac vi hoai t te bao, t huy te bao chu yeu la 1 hien tng sinh ly bnh thng, rat can
thiet trong qua trnh tao hnh cac mo-c quan trong giai oan phoi thai. Trong giai oan sau
sinh, t huy te bao am bao s on nh ve cau truc va chc nang cua nhieu loai mo khac nhau,
loai bo nhng te bao khong con can thiet ; th du:
- Cau truc tuyen Lieberkhn c oi mi lien tuc nh vao s t huy cua cac te bao bieu
mo be mat niem mac ruot, nhng cho cho cac te bao bieu mo mi sinh ra tai ay tuyen di
chuyen len.
- tuyen c, cac te bao T chong lai khang nguyen cua chnh c the se b loai bo bang c
che t huy te bao. Tai trung tam mam cac nang limpho th cap trong hach bach huyet, cac
limpho bao B co ap ng kem vi khang nguyen se t huy, phan cat thanh cac the t huy va
c ai thc bao an.
- tuyen vu sau khi ngng hoat ong tao sa, 90% te bao bieu mo tuyen se t huy.
Trong mot so tnh trang benh ly, tac ong cua cac yeu to oc hai ben ngoai nh tia xa,
goc oxi hoa t do, hoa chat, nhiem virus...co the gay ton thng phan t ADN trong nhan, lam
cho cac phan t protein b ket trong li noi bao do gap cuon sai chuoi polypeptid; te bao se
t huy neu khong sa cha c. ay la 1 c che bao ve giup c the loai bo nhng te bao
mang ot bien gen co tiem nang chuyen dang thanh te bao ung th.
C che t huy te bao uc thc hien theo 2 ng, noi sinh- ty the va ngoai sinh- thu the
chet, trong o ng th nhat xay ra nhieu hn (Hnh 27).
a. ng noi sinh-ty the (mitochondrial-intrinsic pathway):
Te bao t huy la do hoat ong cua cac protein ieu hoa s t huy thuoc ho bcl-2 co trong
dch bao tng, phan thanh 2 nhom vi tac ong oi nghch nhau:
- Cac protein thuc ay t huy te bao: Bax, Bak, Bad, Bim, Bid, Bik, Nox, Puma, Noxa,..
- Cac protein c che t huy te bao: Bcl-2, Bcl-XL, Bcl-X, A1, Ku70, Mcl-1,..
Hinh 27: Hai con ng t huy te bao
Tuy theo moi can bang hoat ong gia 2 nhom nay ma te bao se b thuc ay i vao t
huy hay la khong:
Khi te bao hoat ong bnh thng, hoat ong cac protein c che t huy Bcl-2, Bcl-XL
chiem u the se bat hoat Bax va Bak, ngan can khong cho protein cytochrom c t trong khoang
gian mang cua bao ti the i ra ngoai bao tng.
Khi te bao tr nen khong con can thiet trong c the, hoac co mang nhng ton thng
khong sa cha c tren ADN va protein; cac protein Bim, Bid, Bad se ngay lap tc nhan biet
tnh trang nay va hoat hoa Bax va Bak; Bax va Bak se di chuyen en mang ngoai bao ti the, tao
thanh kenh dan xuyen mang cho phep cytochrom c thoat vao dch bao tng. Trong bao tng,
cytochrom c se hoat hoa 1 chuoi cac enzym caspase co kha nang phan cat ac hieu ADN va
protein cua bo xng te bao, khien nhan b phan thanh nhieu manh nho va te bao thanh cac
the t huy. Khac vi hoai t te bao, cau truc mang te bao va mang bao quan van bnh thng,
ty the va tieu the con nguyen ven, khong nt v. ai thc bao nuot tron the t huy ch trong vai
phut; s nhanh nhen nay la do ai thc bao co cac thu the tng ng vi cac phosphatidylserin
tren be mat cua the t huy ( te bao song, phosphatidylserin phan bo mat trong mang te bao
nhng khi te bao t huy, no se c chuyen ra mat ngoai) va cung nh the ma khong co thanh
phan noi bao nao cua te bao t huy b that thoat ra ben ngoai e kch thch phan ng viem.
b. ng ngoai sinh- thu the chet (death receptor-extrinsic pathway):
Cac thu the chet co tren be mat te bao, la cac protein thuoc ve ho thu the TNF, trong o
2 loai c biet ro nhat la thu the TNF typ 1 va FAS. Khi co chat gan tng ng la TNF-alpha va
FASL en gan vao thu the th phc hp hnh thanh co kha nang hoat hoa chuoi cac enzym
caspase, dan en ket cuc la te bao b cat thanh cac the t huy tng t nh tren.
Bang di ay tom tat cac iem khac biet gia hoai t te bao va t huy te bao:
Hoai t te bao T huy te bao
Nguyen nhan Do cac tac nhan benh ly Chu yeu do tac nhan sinh ly,
co the do 1 so tac nhan benh ly
Mc o So lng nhieu Te bao rieng le, so lng t
Anh hng chc nang mo Khong anh hng chc nang mo
Hnh thai:
- The tch te bao Tang Giam
- Nhan Nhan ong, nhan v, nhan tan Nhan phan thanh cac manh nho
- Bao tng Giam tnh bat mau kiem, tang tnh am ac
bat mau acid, xoa m cau truc
- Bao quan Trng phong Nguyen ven
- Mang Mat tnh tham chon loc Bnh thng
Ket qua Te bao no tung, giai phong cac Te bao phan thanh cac the t huy,
chat trung gian hoa hoc. Kch thch c ai thc bao an. Khong kch
phan ng viem thch phan ng viem
C. CAC HNH THAI MO HOC CUA HOAI T

Khi 1 mo co qua nhieu te bao b hoai t cung luc th c goi la mo hoai t. Mo hoai t co
the co nhng hnh thai rieng biet nh sau:
a/ Hoai t ong (coagulative necrosis):
La dang thng gap nhat va ac trng cho hoai t do thieu oxy. Th du: hoai t ong
trong nhoi mau c tim. Mo hoai t chac, mau trang uc. Di KHVQH, mo la 1 am te bao ong
nhat bat mau acid, nhan thng b tan. Tuy nhien, cau truc mo van c bao ton nen con nhan
dien c (Hnh 28).
Hnh 28: ai the va vi the cua hoai t ong trong nhoi mau c tim
C che cua hien tng nay co le do tnh trang toan hoa noi bao trong te bao hoai t a
lam bien chat cac protein ke ca cac enzym tieu the do o c che s t tieu te bao. Hoai t ong
ch ton tai trong 1 thi gian sau o chuyen thanh hoai t hoa long do hien tng d tieu.
b/ Hoai t hoa long (liquefactive necrosis):

Mo hoai t mem nhun, mau nht nhat, thng hoa long gia. Hnh anh vi the la mot
am chat vo nh hnh cha ay cac manh vun te bao hoai t. C che cua hoai t hoa long la
do hoat ong manh me cua cac enzym tieu the (t tieu hoac d tieu). Gap trong ton thng mo
nao do thieu oxy (nhun nao), cac o viem do vi khuan sinh mu (ap xe) (Hnh 29).
Hnh 29: ai the va vi the cua hoai t hoa long trong ap xe thanh bung
c/ Hoai t m (fat necrosis):

Mo m b hoai t tao ra cac vet mau trang nga chac, thng gap trong viem tuy cap. Hnh
anh vi the la cac te bao m b hoai t khong con thay ro ranh gii gia cac te bao, thng co
lang ong calci va tham nhap te bao viem (Hnh 30).
Hnh 30: ai the va vi the cua hoai t m trong viem tuy cap
d/ Hoai t ba au (caseous necrosis):

La 1 dang hoai t ac biet gap trong viem lao. Mo hoai t la 1 chat b mau trang tng t
ba au. Hnh anh vi the cho thay cau truc mo b pha huy hoan toan, thay vao o la 1 chat vo
nh hnh dang hat, cau tao bi cac manh v cua cac te bao b hoai t (Hnh 31).
e/ Hoai t hoai th (gangrenous necrosis):

Con goi la hoai th, tuy khong thc s la 1 hnh thai mo hoc rieng biet cua hoai t, nhng
thuat ng nay van con c quen dung trong lam sang e mo ta dang ai the cua ton thng
chi do tac ong mach. Phan biet 2 loai:
- Hoai th kho: phan chi b hoai th co mau tm va kho. Vi the la hnh anh hoai t ong.
- Hoai th t: la giai oan tiep sau hoai th kho. Di tac ong cua vi khuan va
cac bach cau, vung hoai th kho b phan huy tr nen lay nhay, t, hoi. Hnh anh vi the la hoai
t hoa long. (Hnh 32)
Hnh 31: ai the va vi the cua hoai t ba au trong lao than (*)
Hnh 32: Hoai th kho (A); Hoai th t (B)

MOT SO CAU HOI T LNG GIA
1. T cung cua mot phu n mang thai to ra la nh te bao c trn t cung:

A/ Tang san B/ Ph ai C/ Chuyen san
D/ A va B ung E/ Tat ca A, B, C ung
2. Mot benh nhan nam 51 tuoi co huyet ap 160/100 mmHg trong nhieu nam ma khong ieu tr, te
bao c tim co the b loai ton thng sau:
A/ Teo et te bao B/ Ph ai C/ Chuyen san
D/ Tang san E/ Nghch san
3. Hien tng bieu mo tuyen tru n co t cung c thay bang bieu mo lat tang ma 2/3 di
cua chieu day bieu mo co cac te bao to nho khong eu, nhan tang sac, nh hng sap xep b
roi loan th c goi la:
A/ Chuyen san gai B/ Nghch san nhe C/ Nghch san va
D/ Nghch san nang E/ Carcinom tai cho
4. Tnh trang gan to, mem, mau vang ong ngi nghien ru la do:
A/ Ru c che s oxy hoa cac acid beo trong ty the cua te bao gan
B/ Te bao gan b ong m trong bao tng
C/ Tang so lng te bao m trong tieu thuy gan
D/ Tat ca A, B, C ung E/ Ch A va B ung
5. S calci hoa mang x va ong mach:

A/ La 1 hien tng lang ong ngoai bao
B/ Thuoc loai calci hoa nghch dng
C/ Thuoc loai calci hoa di can
D/ A va B ung E/ A va C ung
6. KHONG PHAI la ac iem hnh thai cua te bao hoai t :

A/ Nhan ong B/ Nhan quai C/ Nhan v
D/ Nhan tan E/ Bao tng tang tnh bat mau axt
7. T huy te bao co ac iem:

A/ So lng te bao hoai t t B/ Khong anh hng en chc nang cua mo
C/ Thu hut bach cau a nhan D/Tat ca A,B,C ung E/ Ch A va B ung
8. Bang phng phap nhuom thong thng hematoxylin-eosin, ban chat cua nhng hat mau nau
c thay trong bao tng te bao gan co the la:
A/ Lipofuscine B/ Bilirubin C/ Hemosiderin
D/ Ch A, B ung E/ Tat ca A, B, C ung
9. S xuat hien the vui hyalin trong bao tng thng do ton thng ong noi bao cua:
A/ Glycogen B/ Mucopolysaccharide C/ Protein
D/ Lipid E/ Sac to hyalin
10. KHONG PHAI la hien tng chuyen san:

A/ Bieu mo tru gia tang phe quan bien thanh bieu mo lat tang
B/ Bieu mo tru n co trong co t cung bien thanh bieu mo lat tang
C/ Bieu mo hoa voi
D/ Mo si chuyen thanh mo sun
E/ Mo si chuyen thanh mo xng
Viem va sa cha 33
VIEM va SA CHA
Muc tieu:
1. Neu ro va phan tch nh ngha cua viem.
2. Mo ta va giai thch cac ac iem mo hoc cua viem cap tnh.
3. Neu nguon goc va cac tac dung chnh cua chat trung gian hoa hoc.
4. Mo ta va giai thch cac ac iem mo hoc cua viem man tnh va viem hat.
5. Neu ro va phan tch 2 hnh thc cua qua trnh sa cha ton thng.
Viem la 1 phan ng cua he thong vi tuan hoan dan en s di chuyen dch va bach cau
t trong mau ra cac mo ngoai mach; nham bao vay va loai tr cac vi sinh vat, cac khang
nguyen, cac te bao chet, cac vat the la,...
Phan ng viem luon cap oi vi 1 qua trnh sa cha nham phuc hoi lai mo ton thng
theo 2 cach, tai tao hoac hoa seo.
Ve c ban, phan ng viem va sa cha la co li, nhng oi khi hoat ong cua no co the
gay ra nhng hau qua tai hai (th du: bien dang va cng khp trong viem khp man, seo loi da
co gay mat tham my).
Tuy theo ac iem lam sang va mo hoc, phan biet 3 loai viem: viem cap tnh, viem man
tnh va viem hat.
VIEM CAP TNH
ac iem lam sang cua viem cap la khi phat ot ngot, dien tien nhanh t vai gi en
vai ngay, vung mo b ton thng (con goi la o viem cap tnh) co dau hieu sng, nong, o, au;
trng hp viem nang co them tnh trang mat chc nang rieng biet cua mo va c quan tng
ng. (Hnh 1)
Hnh 1: O viem cap tnh ngon tay cai do vet can
Nguyen nhan cua viem cap la tat ca cac tac nhan co the lam ton thng mo va gay hoai
t te bao:
- Thieu oxy.
- Vat ly: chan thng, bong, tia xa, d vat.
- Hoa hoc: axt, baz, dc pham, oc to.
- Nhiem khuan: vi khuan, ky sinh trung, virut, nam moc.
- Phan ng mien dch: qua man, t mien.
Viem va sa cha 34
3 ac iem mo hoc chnh cua viem cap la: sung huyet ong, phu viem va tham nhap te
bao ma chu yeu la cac bach cau a nhan trung tnh.
1. Sung huyet ong (active hyperemia)
Sung huyet la tnh trang tang qua mc lng mau trong mo-c quan. Sung huyet trong
viem cap la mot sung huyet ong, ket qua cua 1 bien oi huyet ong hoc trong he thong vi tuan
hoan. Khi au co 1 s co that thoang qua cac tieu ong mach (khoang vai giay) do phan xa
than kinh; tiep sau o, di tac ong cua cac chat trung gian hoa hoc c phong thch t te
bao-mo b thng ton ma quan trong nhat la prostaglandin, hiastamin va oxid nitric, cac c trn
tieu ong mach va c that tien mao mach gian ra lam mau chay ua vao cac mao mach va tieu
tnh mach, gay ra sung huyet ong vung mo viem, tao ra trieu chng nong o cua o viem tren
lam sang. (Hnh 2)
Hnh 2: Do s gian ra cua c trn tieu ong mach (1) va c that tien mao mach (2),
mau chay ua vao li mao mach (3) va tieu tnh mach (4)
Hnh anh vi the cua sung huyet ong la cac mach mau gian rong, cha ay hong cau.
(Hnh 3)
Hnh 3: Tieu tnh mach gian rong cha ay hong cau
2. Phu viem (inflammatory edema)

Do ong dch xuat trong mo ke ngoai mach mau tai o viem. Dch xuat nay con goi la
dch phu viem, co ham lng protein 3g%, d >1,020; c hnh thanh do 2 c che:
- S tang ap lc thuy tnh trong cac mao mach, la ket qua trc tiep cua tnh trang sung
huyet ong neu tren.
- S tang tnh tham thanh mach, la c che chnh gay ra phu viem. S tang tnh tham thanh
mach xay ra chu yeu tai cac tieu tnh mach. Bnh thng cac te bao noi mo nam ta tren mot
Viem va sa cha 35
mang ay va c lien ket vi nhau bang lien ket vong bt (Hnh 4); do o cac protein huyet
tng trong long mach khong the thoat vao mo ke c.
Hnh 4: Te bao noi mo lien ket nhau bang lien ket vong bt (mui ten)
Trong phan ng viem, cac chat trung gian hoa hoc c giai phong t cac te bao va mo
ton thng nh histamin, seretonin, yeu to hoat hoa tieu cau (PAF: platelet activating factor),
prostaglandin, leukotrien, san pham giang hoa t fibrin, bradykinin se tac ong len tieu tnh
mach bang cach gan ket vi cac thu the tng ng co tren be mat te bao noi mo. S gan ket
lam te bao noi mo co lai, e lo ra cac khoang h cho phep cac protein huyet tng lot vao mo
ke ngoai mach (Hnh 5). S gia tang nong o protein trong mo ke lam tang ap lc tham thau keo
tai ay, ket qua nc va chat ien giai a b ay ra ngoai do s tang ap lc thuy tnh th lai cang
b keo them ra, lam gia tang lng dch phu viem. Hien tng phu viem nay tao ra bieu hien
sng cua o viem. Trieu chng au la do cac tan cung than kinh b cang gian do dch phu viem
hoac do b kch thch trc tiep bi cac chat trung gian hoa hoc.
Hnh 5: Te bao noi mo co lai, e lo ra cac khoang h

Viem va sa cha 36
Hnh anh vi the cua hien tng phu viem la mot mo ke long leo ay dch xuat. (Hnh 6)
Hnh 6: Mo ke long leo ay dch xuat
S hnh thanh phu viem co cac tac ong tch cc nh:

* Pha loang cac tac nhan gay viem.
* a vao mo ke cac khang the va bo the giup trung hoa hoac bat hoat cac khang nguyen
va oc to.
* a cac yeu to ong mau vao trong mo ke. S hoat hoa he thong ong mau tao ra hang
rao fibrin giup ngan chan s lan rong cua tac nhan gay viem.
Tuy theo ban chat hoa hoc va thanh phan te bao cha ben trong, phan biet cac loai dch
xuat sau:
- Dch xuat thanh huyet (serous exudate): dch trong va co mau vang nhat tng t huyet
thanh, gom nc, chat ien giai ,cac protein huyet tng nhng rat t fibrin, gap trong cac phan
ng viem nhe. Dch xuat co the ong trong cac khoang mang bung, mang phoi, bao tim gay
tran dch mang bung, tran dch mang phoi, tran dch mang tim. (Hnh 7A)
- Dch xuat t huyet (fibrinous exudate): la dch xuat thanh huyet co cha them 1 lng
ln fibrin c hnh thanh do s hoat hoa he thong ong mau, gap trong cac phan ng viem
nang hn. Khi co dch xuat t huyet ong tren be mat cac mang nh mang tim, mang phoi th
goi la viem mang tim t huyet, viem mang phoi t huyet. (Hnh 7B)
- Dch xuat xuat huyet (hemorrhagic exudate): la dch xuat thanh huyet cha nhieu hong
cau, do o co mau o lt. (Hnh 7C)
- Dch xuat mu (purulent exudate): la dch xuat thanh huyet co cha nhieu bach cau a
nhan, ai thc bao, xac te bao chet va cac vi sinh vat. Dch xuat mu co the ngam lan toa trong
mo ton thng hoac tap trung lai tao thanh 1 o mu hay con goi la ap-xe. (Hnh 7D)
Viem va sa cha 37
Hnh 7: Dch xuat thanh huyet (*) (A); Dch xuat t huyet (*) (B); Dch xuat xuat huyet (C); Dch xuat mu (D)
3. S tham nhap te bao

La bien oi quan trong nhat trong phan ng viem cap. Di tac ong cua cac chat trung
gian hoa hoc, cac bach cau se di chuyen t trong long mach vao mo ke e en tap trung tai
vung mo ton thng. S di chuyen cua bach cau cung xay ra chu yeu tai cac tieu tnh mach,
gom 3 giai oan la tu vach, xuyen mach va hoa ng ong.
- Tu vach (margination & adherence):

La hien tng cac bach cau bam vao be mat cac te bao noi mo, chu yeu tai tieu tnh
mach (Hnh 8, 9).
Viem va sa cha 38
Hnh 8: Tu vach, bach cau bam vao be mat cac te bao noi mo
Hnh 9: Hien tng tu vach xay ra tieu tnh mach, khong thay tieu ong mach
Hien tng tu vach xay ra do 2 c che sau:

* Tnh trang sung huyet ong va tang tnh tham thanh mach lam mau b co ac hn va
chay cham lai, thuan li cho s tiep can gia bach cau va be mat te bao noi mo. (Hnh 10)
Hnh 10: Mau co ac va chay cham, thuan li cho s tiep can gia bach cau va te
bao noi mo tai vung tieu tnh mach.
Viem va sa cha 39
* S gan ket gia cac phan t ket dnh (cell adhesion molecule) tng ng co tren be
mat cac te bao noi mo va bach cau (tng t cha khoa va o khoa). Co 3 nhom phan t ket dnh
la selectin, integrin va globulin mien dch; cac phan t nay hoac a co san trong te bao hoac va
mi c tong hp nhng noi chung ch hoat ong khi co kch thch cua cac chat trung gian hoa
hoc (Hnh 11 va bang 1).
Khi au, cac lien ket gia chuoi Sialyl-Lewis X vi P-selectin va E-selectin cha u
manh e bach cau bam chat, nen no van tiep tuc lan tron tren be mat te bao noi mo cho en khi
integrin c hoat hoa tang ai tnh. S gan ket gia integrin vi ICAM-1 giup bach cau bam
chat, ngng lan va chuyen sang giai oan xuyen mach (Hnh 11, 12).
Hnh 11: S gan ket gia cac phan t ket dnh tng ng co tren be mat cac te bao noi mo va bach cau
Bang 1: Cac phan t ket dnh te bao noi mo bach cau:
Te bao noi mo Bach cau Vai tro chnh

P-selectin Chuoi ng ngan Sialyl-Lewis X Lan
E-selectin Chuoi ng ngan Sialyl-Lewis X Lan va ket dnh
GlyCam-1, CD34 L-selectin Lan
Globulin mien dch (ICAM-1, V-CAM-1) Integrin Ket nh, ngng lan, xuyen mach
GlyCam-1: glycosylation-dependent cell adhesion molecule, ICAM-1: Intecellular adhesion molecule 1; VCAM-1: vascular
cell adhesion molecule)
Viem va sa cha 40
- Xuyen mach (diapedesis, transmigration):
Sau khi a bam chat len be mat te bao noi mo, bach cau tho cac chan gia vao gia khe
gian bao e xuyen qua lp te bao noi mo, tiet collagenase phan huy mang ay va chui vao mo
ke. Trong vong 24 gi au, bach cau xuyen mach chu yeu la cac bach cau a nhan trung tnh
(Hnh 13), trong 24 gi ke tiep la cac mono bao; ngoai ra con co cac hong cau di chuyen theo
cac bach cau. Hien tng xuyen mach xay ra chu yeu cac tieu tnh mach; thong qua s tng
tac gia cac phan t ket dnh tng ng cung co tren be mat bach cau va te bao noi mo, th du
nh phan t PECAM-1 (platelet endothelial cell adhesion molecule - thuoc nhom globulin mien
dch) (Hnh 12).
Hnh 12 : Cac giai doan cua hien tng tham nhap bach cau
Hnh 13: Bach cau a nhan xuyen qua lp te bao noi mo, phan huy mang ay e chui vao mo ke
Viem va sa cha 41
- Hoa ng ong (chemotaxis):
Trong mo ke, bach cau di chuyen theo 1 chieu hng nhat nh - hng en vung mo b
ton thng - nh vao tac ong cua cac yeu to hoa ng ong. Cac yeu to hoa ng ong c
phong thch tai o viem, co the la 1 chat ngoai sinh hoac noi sinh. (Hnh 14)
* Ngoai sinh: la cac thanh phan lipid va peptid co trong cau tao cua vi khuan
* Noi sinh: la mot so chat trung gian hoa hoc c giai phong trong phan ng viem nh
yeu to bo the C5a, leukotrien, interleukin-8, yeu to hoat hoa tieu cau.
Cac yeu to hoa ng ong tac ong bang cach gan ket len cac thu the tng ng tren be
mat bach cau lam tang calci noi bao, kch thch hoat ong cua he thong actin - myosin trong bao
tng, giup cho bach cau di chuyen c. (Hnh 14)
Hnh 14: ai thc bao ang di chuyen (A); tho ra cac chan gia bat lay vat la (hat men).
Hnh anh vi the cua hien tng tham nhap te bao la s hien dien cua rat nhieu bach cau
trong mo ke ngoai mach (Hnh 15).
Hnh 15: S tham nhap bach cau a nhan trong mo ke ngoai mach cua mot viem voi trng cap tnh
Viem va sa cha 42
4. Hoat ong thc bao cua cac bach cau tai o viem
Chu yeu la hoat ong cua bach cau a

nhan trung tnh va ai thc bao, gom 3 bc:
(Hnh 16).
- Nhan biet va ket dnh vi vat the can
thc bao (recognition & attachment):
Qua trnh nay tr nen de dang hn neu
vat the c bao boc bi cac opsonin, la chat
ma cac bach cau va ai thc bao co thu the be
mat tng ng. Hai loai opsonin chnh la manh
bo the C3b va manh Fc cua IgG
- Om bat (engulfment):
Sau khi a gan c vi oi tng, bach
cau tho ra cac chan gia om lay e a no vao
Hnh 16: ai thc bao ang an vi khuan E. coli
trong 1 tui thc bao (phagosome).
- Tieu hoa (digestion):

Tui thc bao hoa nhap vi cac tieu the s cap thanh tieu the th cap (khong bao tieu hoa)
ma trong o vat the se b phan huy bi cac enzym tieu the. Neu vat the la vi khuan, no se b tieu
diet bi cac san pham chuyen hoa co tnh oxid hoa rat manh c tong hp t oxy ben trong
- -
tieu the th cap nh peroxid hydro (H2O2), superoxid (O2 ), goc hydroxyl (OH ), axt hypochloro
(HClO-) (Hnh 17).
Hnh 17: Ba bc cua hoat ong thc bao (A). S hnh thanh cac san pham chuyen hoa co tnh oxid hoa
manh trong tieu the th cap e tieu diet vi khuan (B).
Viem va sa cha 43
5. Hng dien tien cua viem cap: (Hnh 18)
- Tan hoan toan: neu mo ch b ton thng nhe, phan ng viem tieu huy hoan toan tac
nhan gay ton thng. Cac chat trung gian hoa hoc c trung hoa lam tnh tham thanh mach tr
lai bnh thng va s tham nhap te bao ngng lai. ai thc bao thu don cac manh vun te bao
chet; dch phu c dan lu tr vao cac mach bach huyet. Ket qua la cau truc mo lai c phuc
hoi nh cu.
- Hoa seo: khi mo b ton thng qua nhieu, mo thuoc loai khong tai tao c (th du: mo
c tim) hoac co qua nhieu dch xuat t huyet kho tai hap thu, khi o qua trnh sa cha se tao ra
mo si thay the cho mo hoai t goi la hien tng hoa seo.
- Ap-xe hoa: xay ra khi tac nhan gay ton thng la cac vi khuan sinh mu va mo b ton
thng nhieu. Mo hoai t hoa long tao thanh o ap-xe.
- Chuyen thanh viem man: neu phan ng viem cap khong loai tr c tac nhan gay ton
thng.
Hnh 18: Hng dien tien cua viem cap
6. Chat trung gian hoa hoc

Khi te bao va mo a b ton thng, du do bat ky nguyen nhan g, cung se co s giai phong
cac chat trung gian hoa hoc; chnh tac ong cua chung a tao ra cac bien oi mo hoc cua viem
cap cung nh mot so bieu hien lam sang va can lam sang khac thng gap nh sot, met, chan
an, tang so lng bach cau trong mau...
Cac chat trung gian hoa hoc co nguon goc t te bao hoac t huyet tng:
- Te bao: cac te bao cua mo ton thng, te bao noi mo, cac bach cau, tieu cau, masto
bao, ai thc bao la nguon goc cua nhieu chat trung gian hoa hoc quan trong; cac chat nay
hoac a co san trong te bao (th du: histamin trong masto bao) hoac va mi c tong hp khi
co phan ng viem (th du: leukotrien, prostaglandin, thromboxane t cac phan t phospholipid
mang) (Hnh 19, 20).
Hnh 19: Cac masto bao luon co san quanh mach mau
Viem va sa cha 44
Hnh 20 : Cac chat trung gian hoa hoc c tong hp t phospholipid mang
- Huyet tng: nhieu chat trung gian hoa hoc khac nhau c hnh thanh do s hoat hoa
va tac ong lan nhau gia 4 he thong enzym trong huyet tng la he thong ong mau, he thong
kinin va he thong tieu fibrin va he thong bo the. (Hnh 21)
Hnh 21: Chat trung gian hoa hoc do s hoat hoa cua 4 he thong enzym trong huyet tng
Bang sau ay tom tat nguon goc va tac dung cua 1 so chat trung gian hoa hoc chnh trong
phan ng viem cap.
Viem va sa cha 45
Bang 2: Nguon goc va tac dung cua 1 so chat trung gian hoa hoc chnh trong viem cap
Chat TGHH Nguon goc Tac dung
Tang TTTM Hoa ng ong Khac
Histamin, seretonin Masto bao, TC + -

Prostaglandin BC, TC, TBNM, Tang tac ong - Gian mach, sot, au
Masto bao cac TGHH khac
Leukotrien BC +/- +/- BC tu vach
Yeu to hoat hoa TC (PAF) BC, Masto bao + + BC tu vach, xuyen mach
Interleukin, TB, TBNM - + Sot, au
Yeu to gay hoai t u
Oxid nitric TB, TBNM Gian mach
HT. Bo the: C3a + - Opsonin C3b
C5a + + BC tu vach
HT. Kinin: Bradykinin HUYET + - au
HT ong mau: TNG + +
Thrombin, fibrinopeptid
HT tieu fibrin: +
San pham giang hoa tu fibrin
Chu thch: BC: bach cau; TB: ai thc bao; TC: tieu cau; TBNM: te bao noi mo.
VIEM MAN TNH

La phan ng viem keo dai nhieu tuan, nhieu thang, nhieu nam.
Viem man co the phat trien tiep sau 1 viem cap, khi ma tac nhan gay ton thng van con
ton tai cha b tieu diet; viem man cung co the xuat hien ngay t au, trong trng hp nay, no
thng co khi au ngam ngam, am , khong co trieu chng lam sang ro ret. (hnh 22)
Hnh 22: O viem loet da man tnh tren mat ca chan
Nguyen nhan cua viem man c ban cung la cac nguyen nhan gay viem cap; iem khac
biet la tac nhan gay ton thng van con ton tai hoac co roi loan trong qua trnh sa cha nen
phan ng viem b keo dai.
Viem man co hai ac iem mo hoc chnh:
- Tham nhap te bao n nhan.
- Tang sinh mo lien ket - mach mau.
Viem va sa cha 46
1. Tham nhap te bao n nhan
Bao gom cac ai thc bao, tng bao, limpho bao; trong 1 so viem man do ky sinh trung
th co them cac BCN ai toan; cac te bao nay hoat ong tng tac vi nhau nham tieu huy cac
tac nhan gay ton thng. (Hnh 23)
Hnh 23: Viem voi trng man, mo em tham nhap limpho bao, tng bao va ai thc bao (mui ten)
a/ ai thc bao (TB): la thanh phan te bao tru cot trong phan ng viem man, v chnh no
la nguon goc cua nhieu chat trung gian hoa hoc (Interleukin, TNF, oxid nitric, cac yeu to tang
trng nh PGDF, FGF, TGF beta) co kha nang tac ong len hoat ong cua nhieu loai te bao
khac nh limpho bao, nguyen bao si, te bao noi mo; mat khac 1 so chat do TB san xuat lai to
ra oc hai oi vi te bao va mo (san pham chuyen hoa cua oxy, protease), co the lam mo b pha
huy them 1 cach ang ke neu chung thoat c ra ngoai.
Co 3 c che lam cho TB

c tap trung ong ao tai o viem
man (Hnh 24):
- Cac mono bao tiep tuc c
thu hut t long mach vao o viem e
chuyen thanh TB di tac ong cua
yeu to hoa ng ong phong thch t
cac TB va limpho bao trong o viem,
th du nh TNF alpha, interleukin-8.
- Tang sinh tai cho cua cac
TB: TB tien hanh phan bao tao ra
nhieu TB mi.
- c che s di chuyen cua
TB ra khoi o viem di tac ong
cua yeu to c che di chuyen (MIF) do
limpho bao san xuat.
Hnh 24: C che tap trung ai thc bao tai o viem man
Viem va sa cha 47
b/ Limpho bao: limpho bao cac loai (B,T) c huy ong en o viem e thc hien cac ap
ng mien dch dch the va mien dch qua trung gian te bao nham tieu huy tac nhan gay viem.
c/ Tng bao: san xuat cac khang the ac hieu chong lai cac khang nguyen co trong cac
tac nhan gay viem.
2. Tang sinh mo lien ket - mach mau

Nham sa cha cac ton thng gay ra bi cac tac nhan gay viem cung nh bi chnh hoat
ong cua cac TB. (Hnh 25)
Hnh 25: Tang sinh mo lien ket va mach mau. Mach mau tan sinh co te bao noi mo ln
a/ Tang sinh mach mau: di tac ong cua cac yeu to tao mach nh FGF* do TB san
xuat, cac mach mau co san se phan nhanh tao ra cac mach mau mi trong vung ton thng goi
la cac mach mau tan sinh. ac iem cua mach mau tan sinh la te bao noi mo cua no ln hn
bnh thng va oi khi co hnh anh phan bao (hnh 26).
Hnh 26: C che tang sinh mach mau

Viem va sa cha 48
b/ Tang sinh mo lien ket: di tac ong cua cac yeu to tang trng do TB san xuat
nh PDGF, TGF beta; cac te bao trung mo c huy ong en vung ton thng, biet hoa thanh
nguyen bao si, tien hanh phan bao va tong hp cac si collagen cung nh cac thanh phan
khac cua chat can ban lien ket nh proteoglycan, fibronectin.
Chu thch: PDGF (platelet derived growth factor): yeu to tang trng t tieu cau; FGF (fibroblast growth
factor): yeu to tang trng nguyen bao si; TGF beta (transforming growth factor): yeu to tang trng chuyen
dang beta; MIF (migration inhibiting factor): yeu to c che di chuyen; TNF alpha (tumor necrosis factor): yeu
to gay hoai t u alpha.
VIEM HAT
La 1 dang ac biet cua viem man, xay ra khi tac nhan gay viem thuoc loai kho tieu huy
c. Cac tac nhan o co the la:
- Vi khuan: Mycobacterium tuberculosis, M. leprae, Treponema pallidum
- Ky sinh trung: Schistosoma mansoni, Schistosoma japonicum, v.v.
- Nam: Cryptococcus neoformans
- Chat hoa hoc: silic, bot talc, tinh the urate
- Ch phau thuat
- Cha ro tac nhan gay ton thng: benh sarcoidosis.
ac iem mo hoc cua viem hat la s hnh thanh cac u hat (granuloma) co ng knh
< 2 mm. Cau tao cua u hat gom 1 tap hp cac TB bien oi goi la cac te bao dang bieu mo
(Epithelioid cell), va 1 vien te bao bao quanh ma chu yeu la cac limpho bao va 1 t tng bao.
(Hnh 27)
Hnh 27 : U hat lao gom tap hp te bao dang bieu mo (2), ai bao Langhans (3), chat hoai t ba au (1) va
vien limpho bao va tng bao (4) (A); o phong ai ln hn cho thay ro cac te bao dang bieu mo (B)
Cac te bao dang bieu mo co nhan hnh bau duc, bao tng sang. Trong vung ngoai vi cua
u hat, cac te bao dang bieu mo thng hoa nhap thanh cac te bao khong lo ng knh 40 - 50
micromet, co the cha en 50 nhan; cac nhan nay c phan bo trong vung ngoai vi cua te bao
(ai bao Langhans) hoac rai rac trong bao tng (ai bao an d vat) (Hnh 28). Tuy theo tac
nhan gay viem, vung trung tam u hat co the cha chat hoai t. oi vi u hat a co lau, co them
mo lien ket gom cac nguyen bao si va si collagen bao quanh.
Viem va sa cha 49
Hnh 28: ai bao Langhans (A) va ai bao an d vat (bot Talc) (B)
C che hnh thanh u hat va dien tien cua u hat co the khac nhau tuy theo tac nhan gay
viem nhng luon luon co 2 yeu to:
- Tnh chat kho tieu huy cua tac nhan gay viem.
- S khi phat ap ng mien dch kieu qua man qua trung gian te bao (qua man typ IV)
chong lai tac nhan nay.
e minh hoa, chung ta khao sat s hnh thanh va dien tien cua u hat trong viem lao, la 1
dang viem hat ien hnh thng gap.
Vi khuan lao thuoc loai kho
tieu huy khong phai do cha nhieu
oc to ma la do cau tao vo bao
cua vi khuan co cha mot so
thanh phan nh yeu to day (cord
factor) co ban chat la mot loai
glycolipid, Lipoarabinomannan
(LAM) la mot loai polysaccharid
phc, co kha nang c che s hoa
nhap gia tui thc bao vi tieu the;
nh vay vi khuan lao b thc bao
van co the tiep tuc song va sinh
san ben trong TB. Ket qua la
TB b tan v; vi khuan lao c
giai phong va qua trnh tren lai tiep
tuc vi cac TB khac. Hinh 29: S hnh thanh nang lao
Sau 2 - 3 tuan, rot cuoc cung co mot so ai thc bao phan huy c vi khuan lao e trnh
dien khang nguyen len be mat. S tng tac gia cac TB co mang khang nguyen cua vi khuan
lao vi limpho bao T se khi phat ap ng mien dch qua trung gian te bao (qua man typ IV); ket
qua hnh thanh cac limpho bao T hoat hoa gom te bao T ho tr CD4+ va te bao T c che CD8+
(con goi la T gay oc te bao).
- Te bao T ho tr CD4+ c hoat hoa se san xuat nhieu chat trung gian hoa hoc nh:
* Yeu to hoai t u alpha (TNF alpha) tac ong len te bao noi mo mach mau, tao ieu
kien cho s tham nhap nhieu hn na cac mono bao va limpho bao t trong long mach mau vao
vung ton thng,
* Interferon gamma lam tang kha nang thc bao va tieu huy vi khuan cua cac TB, ong
thi lam chuyen dang TB thanh te bao dang bieu mo; cac te bao dang bieu mo hoa nhap lai
thanh ai bao Langhans.
Viem va sa cha 50
Ket qua u hat lao c hnh thanh, con goi la nang lao, giup km gi vi khuan lao lai
khong cho phat tan i ni khac. (Hnh 29)
- Mat khac, cac TB a c hoat hoa bi cac te bao T ho tr, se tang san xuat cac yeu
to tang trng nh TGF beta, PDGF co tac dung kch thch s tang sinh mo lien ket, gay hoa si
dan dan vung mo ton thng.
- Te bao T c che CD8+ tieu huy cac TB co mang vi khuan lao cung vi tac ong trc
tiep cua vi khuan lao lam chet cac TB, se tao ra chat hoai t ba au trung tam cua nang lao.
Nang lao co cha chat hoai t ba au gia c goi la nang ba au. Nhieu nang ba
au co the hp nhat vi nhau thanh 1 khoi ln; neu chat ba au thoat het ra ngoai th ch con lai
1 hoc goi la hang lao.
Khi phan ng viem hat a khong che uc vi khuan lao, u hat se chuyen thanh 1 seo x
ngam voi do s tang sinh mo lien ket va lang ong calci trong chat hoai t ba au.
QUA TRNH SA CHA (repair)

Nham phuc hoi lai cau truc mo a b thng ton, phan biet 2 hnh thc:
1. Tai tao (regeneration)

La hoat ong thay the cac te bao a b pha huy bang cac te bao cung loai. Hoat ong tai
tao ch co the phuc hoi c tnh trang cau truc mo nh cu vi 3 ieu kien:
- Mc o hoai t cua mo khong qua ln.
- Khung lien ket mach mau cua mo con nguyen ven.
- Ban than te bao can tai tao co kha nang phan bao.
Th du: te bao gan co kha nang phan bao. Neu gan b hoai t t, khung lien ket mach mau
nang mo gan con nguyen ven, s tang sinh te bao gan se phuc hoi c cau truc tieu thuy
gan bnh thng. Trai lai, neu gan b hoai t nhieu va khung lien ket a b pha huy nh trong
benh viem gan man do virus hay do ru, s tai tao ch tao ra cac am te bao gan ngan cach
nhau bi mo x goi la cac tieu thuy gia, khong phai la cau truc tieu thuy gan bnh thng. (Hnh
30)
Hnh 30: mc o hoai t nhe, te bao gan tang hoat ong phan bao (mui ten) e phuc hoi cau truc
tieu thuy bnh thng (A); Khi hoai t nhieu, s tai tao te bao gan ch tao ra cac tieu thuy gia (B).
Viem va sa cha 51
Te bao c tim, te bao than kinh khong con kha nang phan bao do o neu mo c tim va
mo than kinh b hoai t th ch co the sa cha bang hnh thc hoa seo.
2. Hoa seo (scarring)

La s thay the mo b hoai t bang mo lien ket, xay ra khi ton thng gay mat chat qua
nhieu, hoac khi ton thng xay ra nhng mo ma te bao khong con kha nang phan bao. Dien
tien cua hoa seo gom 3 giai oan:
- Thanh lap mo hat (granulation tissue):
La s tang sinh mo lien ket mach mau trong vung mo ton thng; ket qua hnh thanh 1 mo
hat mau o, mem, be mat lon nhon va de chay mau khi ung en. (Hnh 31)
Trong cac ton thng da, s thanh lap mo hat thai qua se tao ra 1 u gia goi la u hat chum,
loi tren mat da (exuberant granulation). (Hnh 32)
- Hoa si (fibrosis):
Mo hat c chuyen thanh mo lien ket si do cac nguyen bao si gia tang tong hp cac
si collagen. Kch thc mo si nay se c giam bt nh hoat ong cua cac nguyen bao si-c
(myofibroblast).
S tong hp qua ang si collagen se tao ra cac seo loi (keloid) con hoat ong qua mc
cua nguyen bao si-c se tao ra cac seo co keo. (Hnh 33)
- Hoa x (sclerosis):
Cac mach mau cung nh cac nguyen bao si dan dan teo lai va bien mat do b chen ep
bi cac si collagen, ket qua mo si bien thanh mo x. (Hnh 34).
Hnh 31: ai the va vi the cua mo hat
Hnh 32: U hat chum, ai the va vi the

Viem va sa cha 52
Hnh 33: Seo loi va seo co keo
Hnh 34: Vi the cua giai oan hoa si (A) va hoa x (B)
Viem va sa cha 53

1. Bieu hien nong o cua o viem cap tnh la do:
A/ Sung huyet tnh B/ Sung huyet ong C/ Phu viem
D/ Xuat huyet vi the E/ Tang tnh tham thanh mach
2. KHONG PHAI ac iem vi the cua viem cap tnh:

A/ Cac mach mau sung huyet gian rong
B/ ong dch phu viem trong mo ke
C/ Bach cau a nhan tu vach cac tieu ong mach
D/ Tham nhap bach cau a nhan trong mo ke
E/ Xuat huyet vi the
3. Dch xuat t huyet la dch xuat thanh huyet co them nhieu:

A/ Fibrinogen B/ Fibrin C/ Chat ien giai
D/ Bach cau a nhan E/ Hong cau
4. Trong phan ng viem cap, hien tng tu vach, lan va xuyen mach cua bach cau la do hoat
ong tong tac gia cac phan t sau, TR MOT:
A/ P-Selectin B/ L- Selectin C/ Interleukin
D/ Integrin E/ Sialyl-Lewis X
5. KHONG PHAI la chat trung gian hoa hoc c hnh thanh trong phan ng viem cap:
A/ Histamin B/ Hemosiderin C/ Interleukin
D/ Leukotrien E/ Prostaglandin
6. Trong viem cap tnh, s tang tnh tham thanh mach:

A/ Xay ra chu yeu tieu tnh mach
B/ La do tac ong cua chat trung gian hoa hoc
C/ Lam bach cau thoat ra ngoai mach
D/ Ch A, B ung
E/ Tat ca A, B, C ung
7. Trong phan ng viem cap tnh, bach cau xuyen mach :

A/ Tai tieu ong mach B/ Tai tieu tnh mach
C/ Chu yeu la bach cau n nhan trong 24 gi au
D/ Ch A, C ung E/ Ch A, B ung
8. Trong viem cap tnh, hien tng bach cau di chuyen theo 1 hng nhat nh ve pha mo b ton
thng c goi la:
A/ Tu vach B/ Xuyen mach C/ Hoa ng ong
D/ Opsonin hoa E/ Thc bao
9. Tai o viem cap, neu vat the uc thc bao la vi khuan th trong bach cau se xay ra hien tng:
A/ Tang tong hp cac enzym tieu the B/ Tang s dung oxy e tong hp ATP
C/ Bung no tieu thu oxy e tong hp cac san pham chuyen hoa co tnh oxy hoa manh
D/ Tang tong hp chat trung gian hoa hoc E/ Tang tong hp yeu to hoa ng ong
10. Mot em be sau khi i tam bien vai gi th da lng b o rat va noi cac bong nc, ay la phan
ng:
A/ Viem cap tnh vi nhieu dch xuat thanh huyet B/ Viem cap tnh hoa mu
C/ Viem cap tnh xuat huyet D/ Viem man tnh E/ Viem hat
11. Tai o viem man, co tham nhap cac te bao :

A/ Limpho bao B/ ai thc bao C/ Tng bao
Viem va sa cha 54
12. Mot thang sau mo ruot tha, benh nhan thay noi len ngay di seo mo 1 not nho ma cau tao
vi the gom cac si collagen, ai thc bao, ai bao nhieu nhan va mot t limpho bao; thng la do
bien chng:
A/ Viem cap tnh B/ Viem man tnh C/ Viem hat do d vat
D/ Viem lao E/ Viem mu
13. S chuyen dang cac ai thc bao thanh te bao dang bieu mo trong u hat lao, chu yeu la do
tac ong cua mot chat trung gian hoa hoc do limpho bao T ho tr hoat hoa san xuat, co ten:
A/ TNF alpha B/ Interferon gamma C/ IL-1 D/ IL-2 E/ LAM
14. S hnh thanh seo loi trong qua trnh sa cha bang hnh thc hoa seo la do hoat ong qua
mc cua cac:
A/ Nguyen bao si B/ Nguyen bao c C/ Nguyen bao si c
D/ Te bao c van E/ Te bao c trn
Benh ly U 55
BENH LY U
Muc tieu:
1. Neu ro va phan tch nh ngha cua u.
2. Neu c s phan loai u va cach at ten u.
3. Phan tch va so sanh hnh thai ton thng cua u lanh va ac.
4. Phan tch 4 giai oan trong qua trnh phat trien t nhien cua mot u ac.
5. Phan tch mot so ac iem dch te hoc cua ung th.
6. Liet ke va phan tch 3 nhom nguyen nhan gay ung th.
7. Phan tch vai tro cua 4 loai gen trong qua trnh sinh ung.
cac nc phat trien, u ac la nguyen nhan gay t vong ung hang th hai, ch sau cac
benh tim mach. nc ta, tuy cha co mot con so thong ke chnh xac nhng co the d oan so
trng hp t vong do u ac se ngay mot tang, nhat la khi tuoi tho cua ngi dan a c gia
tang mot cach ang ke trong khoang thi gian gan ay (tuoi tho trung bnh > 65 tuoi). Theo Bo
Y te (2002), c lng moi nam ca nc co them 150.000 trng hp ung th mi va 100.000
trng hp t vong do ung th.
I. nh ngha:
U la 1 khoi mo tan san (neoplasm), c hnh thanh do s tang sinh bat thng, qua
mc va t ong cua cac te bao c the a b chuyen dang (transformed cell).
Trong y khoa, nganh hoc chuyen nghien cu ve cac loai u c goi la ung bu hoc
(oncology).
Trong giai oan phoi thai, qua trnh tang trng va biet hoa e hnh thanh cac loai mo va
c quan khac nhau khien nhieu loai te bao b mat i kha nang sinh san, kha nang nay ch con
c duy tr cac te bao goc ( th du: te bao lp ay cua bieu b, te bao tuy trong tuy xng,
v.v...). Toc o sinh san trong cac mo c kiem soat chat che bi cac c che ieu hoa tang
trng nham am bao s hiep ong gia chung, phuc vu cho s phat trien cua 1 c the thong
nhat (th du: te bao cua lp ay bieu b co toc o sinh san phu hp nhp o bong troc cua cac te
bao lp be mat ). Toc o sinh san cua te bao trong mo co the c ay nhanh len nham bu ap
cho cac thng ton mo gay ra bi cac tac nhan vat ly, hoa hoc, vi sinh vat (th du: tang sinh mo
lien ket-mach mau trong phan ng sa cha); hoac khi mo b kch thch bi cac hormon ac
hieu tng ng (th du: ph ai tang san c t cung khi mang thai). Khi cac tac nhan kch thch
noi tren khong con na, toc o sinh san lai tr ve bnh thng nh trc.
U co the xuat phat t cac te bao c the a b chuyen dang cua bat ky mo nao trong c
the. Tuy vay, u hay gap hn nhng mo con duy tr hien tng phan bao thng xuyen nh
bieu mo, mo lien ket... Nhng te bao va mo a biet hoa cao khong con hoat ong phan bao nh
mo c tim hoac cac nron th hiem khi b chuyen dang e tao thanh u. Toc o sinh san cua cac
te bao u co the nhanh hoac cham nhng khong bao gi ngng lai, cho du cac tac nhan sinh u
khong con na; noi cach khac, s sinh san cua cac te bao u co tnh t ong, khong con b kiem
soat bi cac c che ieu hoa tang trng bnh thng trong c the. Chnh v vay ma u van tiep
tuc ln len trong khi benh nhan ngay mot suy mon, co the gay t vong neu khong c phau
thuat cat bo kp thi. (Hnh 1)
Hnh 1: U hac to ac
(melanoma) niem mac
mieng (A), tren vi the
cac te bao ung th
ay sac to melanin
trong bao tng (B)
Benh ly U 56
Tnh sinh san t ong cua te bao u giup phan biet cac trng hp sau ay khong phai
la u thc, con goi la u gia hoac ton thng gia u:
- U hat viem, polyp mui. (Hnh 2 A,B)
- Nang bam sinh (nang khe mang, nang giap thiet).
- Nang ong ( boc thng b da, boc nang noan buong trng).
- Cac bien oi hnh thai do roi loan noi tiet (phnh giap, bien oi si boc tuyen vu).
- Hamartom: la 1 d tat bam sinh co dang giong u, c hnh thanh do s tang sinh qua
mc nhng khong co tnh t ong cua cac te bao va mo trng thanh tai ngay chnh v
tr bnh thng cua chung; th du cac hamartom phoi, hamartom vu. (Hnh 2C,D)
- Choristom: cung la 1 d tat bam sinh co dang giong u, cau tao bi cac mo co cau truc
bnh thng nhng khong ung v tr bnh thng cua chung, v vay con c goi la mo
lac cho (heterotopic tissue). Th du 1 am mo tuyen tuy nam trong lp di niem mac
cua thanh da day. (Hnh 2E,F)
Hnh 2: Cac ton thng gia u: polyp mui (A), tren vi the ch la tnh trang viem va phu ne
niem mac mui (B); Hamartom phoi (C), cau tao vi the gom bieu mo ho hap, sun, c trn
trng thanh sap xep lon xon (D); Choristom thanh da day (E), cau tao vi the gom cac
nang tuyen tuy va ong bai xuat (F).
II. Danh phap u:

Da vao dien tien cua u va tac ong cua no oi vi benh nhan, u c phan biet thanh
hai loai chnh:
Benh ly U 57
- U lanh: thng ln cham, khu tru tai cho, khong xam nhap mo xung quanh hoac lan
i ni khac (con goi la di can), khoi han sau cat bo va hiem khi gay t vong cho benh nhan
- U ac: con goi la ung th, thng ln nhanh, xam nhap vao mo xung quanh, cho di can
xa va gay ra t vong.
Ngoai 2 loai tren, con gap mot so loai u co o ac tnh khong ro rang, dien tien kho
lng, c goi la u co o ac tnh giap bien hoac u giap bien ac. U giap bien ac thng ln
cham, xam nhap tai cho, hay tai phat sau cat bo nhng hiem khi di can xa; th du: u ai bao
xng, u diep the vu giap bien, u boc buong trng giap bien
Tat ca cac loai u (ngoai tr cac ung th mau), du lanh hay ac cung eu c tao nen
bi 2 thanh phan can ban: Mo chu u va mo em u. (Hnh 3)
Hnh 3: Phan biet de dang gia mo chu va mo em oi vi u tuyen dang polyp ai trang lanh tnh (A,B) va
carcinom tuyen ai trang (C,D); nhng kho khan oi vi u xuat phat t trung mo, th du nh u c trn lanh
tnh than t cung (E,F), hoac sarcom c trn than t cung (G,H).
Benh ly U 58
- Mo chu U (parenchyma): tao bi cac te bao chuyen dang tc la cac te bao u; chnh
thanh phan nay quyet nh dien tien cung nh ten goi cua khoi u.
- Mo em U (stroma): tao bi mo lien ket, cac mach mau va mach bach huyet; tuy
khong phai la cac te bao u nhng co vai tro nang va cung cap cac chat dinh dng can thiet
cho s tang trng cua khoi u.
S phan biet gia 2 thanh phan tren th de dang oi vi cac u xuat phat t bieu mo
nhng rat kho khan oi vi cac u xuat phat t mo lien ket, v ca 2 thanh phan eu co chung
nguon goc
A. Danh phap u lanh:
Ten cua u c tao ra bang cach gan uoi OMA vao ten loai te bao ma t o u xuat
phat. Th du:
* U lanh xuat phat t mo si la fibroma
* U lanh xuat phat t mo sun la chondroma
oi vi u lanh xuat phat t bieu mo, viec at ten phc tap hn nhieu. Mot so u c at
ten da theo hnh anh ai the, vi the hoac ca hai; so khac lai da theo te bao nguyen uy. Th
du:
* U tuyen (adenoma) la u xuat phat t bieu mo tuyen, hnh anh vi the cho thay u tao bi
cac cau truc tuyen.
* U tuyen boc (cystadenoma) la u tao bi cac boc, lot bi bieu mo tuyen
* U nhu (Papilloma) u xuat phat t cac bieu mo phu (da, ong tieu hoa), hnh anh ai the
va vi the cho thay cau truc giong nh la cay dng x.
* Polyp la u xuat phat t bieu mo phu cua cac niem mac (th du polyp tuyen ai trang)
B. Danh phap u ac:
Cac u ac xuat phat t trung mo va mo lien ket c goi la SARCOM. Th du:
* Sarcom si (fibrosarcoma) la ung th cua mo si.
* Sarcom sun (chondrosarcoma) la ung th cua mo sun.
Cac u ac xuat phat t bieu mo c goi la CARCINOM. Th du:
* Carcinom te bao gai (squamous cell carcinoma) la ung th xuat phat t bieu mo lat
tang.
* Carcinom tuyen (adenocarcinoma) la ung th xuat phat t cac bieu mo tuyen.
* Carcinom te bao gan (hepatocellular carcinoma) la ung th xuat phat t te bao gan.
C. Mot so trng hp ac biet:
- U tuyen a dang cua tuyen nc bot (pleomorphic adenoma): ai a so cac u, du lanh
hoac ac, eu co cac te bao cua mo chu u t nhieu giong nhau; ly do la tat ca cac te bao u eu
c sinh ra t mot te bao chuyen dang au tien (tnh chat n dong).
Hnh 4: U hon hp tuyen mang tai (A); ai the u gii han ro, mat cat ac, ong anh do co vung biet
hoa theo hng sun (B); vi the gom cac am bieu mo tuyen (1) va sun trong (2, C).
Benh ly U 59
Tuy nhien trong 1 so trng hp, te bao chuyen dang co the sinh san va biet hoa theo
nhieu hng khac nhau, tao ra u hon hp nhieu thanh phan. Th du u tuyen a dang tuyen nc
bot, cau tao gom cac am te bao bieu mo nam tren 1 mo em si niem co cha cac o xng
hoac sun, tat ca cac thanh phan khac nhau nay eu co chung 1 nguon goc la cac te bao c -
bieu mo chuyen dang cua tuyen nuc bot. (Hnh 4)
- U quai (teratoma): cau tao gom cac thanh phan te bao va mo rat khac nhau xuat
nguon t ca 3 la phoi - nh bieu mo, xng, sun, mo than kinh - sap xep hon on vi nhau. Cac
thanh phan tren eu c sinh ra t mot te bao mam chuyen dang, la te bao co kha nang biet
hoa thanh bat ky loai te bao nao trong c the (xem hnh 40, 41 trong chng benh ly sinh duc
n).
- Mot so u ac lai c at ten theo kieu u lanh vi uoi OMA. Thi du u ac trung bieu mo
(mesothelioma), ung th hach nguyen phat (lymphoma), u hac to ac (melanoma), u tinh bao
(seminoma). Cac ten goi nay khong hp ly nhng v qua quen dung nen van c gi nguyen.
- Mot so u c at ten theo ten cua tac gia au tien tm ra. Th du sarcom Ewing cua
xng, benh Hodgkin cua hach, limphom Burkitt, sarcom Kaposi, bu Wilms...
Bang sau ay gii thieu ten goi cua mot so u thng gap:
MO NGUYEN UY LANH TNH AC TNH
Chu mo u gom 1 loai

te bao:
- U xuat phat t trung mo:

Mo lien ket U si (fibroma) Sarcom si (fibrosarcoma)
U m (lipoma) Sarcom m (liposarcoma)
U sun (chondroma) Sarcom sun (chondrosarcoma)
U xng (osteoma) Sarcom xng (osteosarcoma)
Noi mo va mo lien quan:
* Mach mau U mach mau (hemangioma) Sarcom mach mau (angiosarcoma)
* Mach bach huyet U bach mach (lymphangioma) Sarcom bach mach (lymphangiosarcoma)
* Trung bieu mo U ac trung bieu mo (mesothelioma)
* Mang nao U mang nao (meningioma) U mang nao xam lan
Mo tao huyet Benh bach cau (leukemia)
Mo limpho Limphom (lymphoma)
Mo c
* C van U c trn (leiomyoma) Sarcom c trn (leiomyosarcoma)
* C trn U c van (rhabdomyoma) Sarcom c van (rhabdomyosarcoma)
- U xuat phat t bieu mo

Bieu mo lat tang U nhu (papilloma) Carcinom te bao gai
Te bao lp ay cua da Carcinom te bao ay
Bieu mo tuyen U tuyen (adenoma) Carcinom tuyen (adenocarcinoma)
U nhu (papilloma) Carcinom dang nhu (papillary carcinoma)
U tuyen boc (cystadenoma) Carcinom tuyen boc (cystadenocarcinoma)
Ngoai b than kinh Not ruoi (nevus) melanom ac (malignant melanoma)
Te bao gan U tuyen te bao gan (adenoma) Carcinom te bao gan
(hepatic cell carcinoma)
Bieu mo nieu U nhu Carcinom nieu mac
Bieu mo nhau thai Nhau nc (hydatidiform mole) Carcinom em nuoi (choriocarcinoma)
Bieu mo sinh tinh U tinh bao (seminoma)
Chu mo > 1 loai te bao nhng

thuoc cung 1 la phoi:
Tuyen nc bot U tuyen a dang tuyen nc Carcinom tren nen U tuyen a dang
bot
Chu mo > 1 loai te bao, thuoc

nhieu la phoi:
Buong trng hoac tinh hoan U quai trng thanh (mature U quai cha trng thanh (immature
teratoma) teratoma)
U quai trng thanh hoa ac
Benh ly U 60
III. Hnh thai ton thng:
A. ai the:
1. Hnh dang:
Thay oi tuy theo loai u va v tr
xuat hien u. U lanh xuat phat t bieu mo
phu th thng co dang mot vung go len
tren be mat, polyp hoac nhu; trai lai u ac
thng co dang khoi san sui, loet, tham
nhiem hoac phoi hp gia 3 dang nay
vi nhau (Hnh 6, 7). Cac u xuat phat t
bieu mo nhng nam sau trong cac tang
(gan, phoi, than) hoac t trung mo th
thng co dang khoi cuc ma tnh chat
lanh ac ch co the xac nh c qua Hnh 6: Dang ai the cua u xuat phat t bieu mo phu.
khao sat vi the.
Hnh 7: Ung th thc quan: dang khoi sui (A), loet (B), tham nhiem (C); Ung th ai trang co ai
the phoi hp ca 3 dang (D).
Benh ly U 61
2. Kch thc:
Tuy theo thi iem phat hien, u co ng knh thay oi t 1-2 cm en 15-20 cm. Tng
quan gia kch thc vi tnh chat lanh ac khong quan trong cho bang toc o phat trien cua khoi
u; mot u ln nhanh thng la u ac.
3. Gii han- vo bao:
U lanh thng co gii han ro, co vo bao si ngan cach vi mo lanh lan can; v vay u co
tnh chat di ong, de dang boc tach cat bo toan bo khoi u (Hnh 8A,C). Tuy nhien cung co
nhng u lanh co gii han ro nhng khong co vo bao (th du u c trn than t cung) va nhng u
lanh co gii han khong ro cung nh khong co vo bao (th du u lanh mach mau).
U ac thng khong co vo bao, gii han khong ro ret do s xam nhap cua te bao ung th
vao mo lanh lan can; v vay u di ong kem, kho boc tach cat bo tron ven khoi u. (Hnh 8B,D)
Hnh 8: U si tuyen vu lanh tnh co vo bao, gIi han ro (A); carcinom tuyen vu khong co vo bao, gii han
khong ro (mui ten, B). U tuyen tuyen giap dang nang lanh tnh, co vo bao, mat cat n dang (C); carcinom
tuyen giap khong co vo bao, gii han khong ro, mat cat khong ong nhat (D).
4. Mat o:
Thay oi tuy theo loai u. U lanh thng co mat o chac hn mo xung quanh. Mat o cua
u ac thng mem b (th du ung th tuyen vu dang tuy, sarcom m) nhng cung co khi rat cng
do phan ng tao si trong mo em u (th du carcinom ong tuyen vu the x chai).
5. Mat cat:
Mat cat cua u lanh thng ong nhat, n dang (th du u m co mau vang, u si tuyen
vu co mau hong) (Hnh 8C); trai lai mat cat cua u ac thng khong ong nhat, nhieu mau sac
do cac hien tng hoai t, xuat huyet trong khoi u (tuy nhien cung co nhng u ac co mat cat rat
ong nhat nh limphom, seminom). (Hnh 8D)
B. Vi the:
1. Cau tao vi the cua u lanh giong het nh mo nguyen uy bnh thng; cac te bao u at
en o biet hoa hoan toan ve cau truc va chc nang giong nh te bao bnh thng. Th du trong
u tuyen tuyen giap dang nang lanh tnh (Hnh 8C), te bao u co cau truc giong te bao nang giap
bnh thng, hp thanh cac tui tuyen co cha chat keo giap do te bao u san xuat. Do hoat ong
tang sinh trong khoi u, co the thay mot t hnh anh phan bao nhng khong bao gi co phan bao
bat thng. Tnh chat lanh tnh cua khoi u con uc khang nh bi s khong tm thay hnh anh
xam nhap vao mo xung quanh va di can en ni khac cua cac te bao u. (Hnh 9)
Benh ly U 62
Hnh 9: U tuyen tuyen giap dang nang lanh tnh co vo bao (mui ten, A); te bao u co hnh thai giong het te
bao nang giap bnh thng, hp thanh nang cha chat keo (B).
2. Cau tao vi the cua u ac c ac trng bi tnh trang suy giam o biet hoa
(anaplasia) - t t en nhieu hoac mat biet hoa hoan toan - ve cau truc va chc nang cua te bao
u, bi s xam nhap cua te bao u vao mo lan can.
a/ ac iem hnh thai te bao u ac:
Cac bieu hien cua tnh trang suy giam o biet hoa gom co:
- Mat o te bao tang, nh hng sap xep b roi loan.
- a dang ve hnh thai va kch thc te bao va nhan, co the thay nhng te bao d dang,
te bao khong lo nhieu nhan, te bao co nhan quai, nhan nhieu thuy, nhan co the vui (Hnh 10).
- Nhan ln, tang sac, mang nhan khong ong eu, chat nhiem sac tho, von cuc; hach
nhan to.
- T le nhan/ bao tng tang, co the at en 1/1 thay v 1/4 en 1/6 nh te bao bnh
thng (tng ng vi tnh trang a boi the trong nhan). (Hnh 10)
Hnh 10: Trong u ac nh carcinom ong tuyen vu (A) hoac sarcom c van (B), co s a dang ve kch thc
cua te bao va nhan; nhan ln. hach nhan to, t le nhan/bao tng tang, co te bao khong lo nhieu
nhan hoac nhan quai.
- T le phan bao tang, phan anh toc o tang sinh cao cua u ac; nhng quan trong hn ca
la co s xuat hien cac hnh anh phan bao bat thng nh phan bao 3 cc, 4 cc hoac a cc
(tng phan vi phan bao bnh thng co 2 cc), phan anh cac roi loan ve cau truc va so lng
cua bo nhiem sac the trong te bao u va cac bat thng cua bo may phan bao. (Hnh 11)
Hnh 11 : Phan bao bnh thng 2 cc (A) va cac phan bao bat thng a cc (B,C,D,E)
Benh ly U 63
- Bao tng co the cha cac the

vui tng ng vi cac san pham bnh
thng hoac bat thng do te bao u
san xuat. Th du bao tng te bao ung
th tuyen ruot gia co the cha chat
nhay nh te bao bieu mo ruot bnh
thng (Hnh 12); cac te bao melanom
ay sac to melanin trong bao tng
(Hnh 1B); bao tng te bao gan ung
th co cha protein phoi AFP (alpha
feto protein) (Hnh 17A).
Hnh 12: Te bao ung th tuyen ruot gia van co the cha chat
chat nhay (mui ten) nh te bao tuyen ruot bnh thng.
b/ S xam nhap vao mo lan can: tnh chat ac tnh cua khoi u con c bieu hien qua
s xam nhap cua cac te bao u vao mo lan can khien ranh gii gia khoi u va mo lanh xung
quanh khong con ro ret. Th du nh s xam nhap cua cac am te bao ung th vu vao trong mo
m va can c ben di u. ac iem nay khong c thay nhng ung th con trong thi ky tien
xam nhap, con goi la ung th tai cho. Th du trong ung th tai cho co t cung, cac te bao ung
th van con nam trong lp bieu mo be mat, cha xam nhap qua mang ay (Hnh 13A), sau mot
thi gian, te bao ung th se pha v mang ay va xam nhap vao mo em ben di, trong o co
cac mach mau va mach bach huyet (Hnh 13B,C). S xam nhap cua te bao ung th vao trong
cac mach mau va mach bach huyet trong khoi u la iem bao co the a co di can xa (Hnh 13D).
Ngoai ra co the thay hien tng hoai t xuat huyet trong khoi u va trong mo lan can.
Hnh 13: Carcinom tai cho (A); Te bao ung th bat au pha mang ay chui xuong mo em (mui ten B); cac
am te bao ung th xam nhap sau xuong mo em (mui ten, C); Mot am te bao ung th xam nhap vao
trong mach bach huyet cua mo em (mui ten, D)
c/ o biet hoa va grad mo hoc:

Do tnh trang suy giam o biet hoa ve cau truc va chc nang cua te bao u, cau truc mo
hoc cua u ac b ao lon khong con giong vi mo nguyen uy bnh thng; tuy theo mc o ao
Benh ly U 64
lon nay t hoac nhieu, ngi ta phan biet u ac thanh 4 o biet hoa : Ung th biet hoa tot, ung
th biet hoa va, ung th biet hoa kem va ung th khong biet hoa.
Trong loai ung th biet hoa tot, cau truc cua mo chu u t b ao lon, nhn giong mo
nguyen uy en mc nhieu khi kho phan biet vi u lanh; th du kho phan biet gia ung th tuyen
giap dang nang vi 1 u tuyen tuyen giap dang nang lanh tnh, gia carcinom te bao gai dang
mun coc da hoac niem mac vi u nhu lanh tnh.
oi vi carcinom te bao gai cua da, ung th co o biet hoa tot neu te bao u con gi
c chc nang giong te bao bnh thng cua mo nguyen uy tc bieu b, ngha la te bao u van
san xuat c keratin, tao ra cau sng giong nh lp sng be mat cua bieu b; ung th co o
biet hoa va khi te bao u khong con tao c cau sng, nhng van lien ket c vi nhau bang
cau lien bao tng t cac te bao thuoc cac lp trung gian cua bieu b. Ung th co o biet hoa
kem, te bao u ch con gi c bao tng mau hong nh co bo xng te bao bang cytokeratin,
giong te bao thuoc cac lp can ay cua bieu b nhng sap xep ri rac, do khong lien ket c
vi nhau bang cau lien bao, khong tao c cau sng. (Hnh 14)
Hnh 14 : Bieu b bnh thng (A); carcinom te bao gai co o biet hoa tot (B), tao c cau sng (mui ten);
o biet hoa va (C), co cau lien bao gia cac te bao u (mui ten); o biet hoa kem (D), te bao u co bao
tong mau hong.
oi vi carcinom tuyen nh carcinom tuyen ai trang. Ung th se co o biet hoa tot, va

kem, hay khong biet hoa tuy theo thanh phan te bao u tao c cau truc tuyen chiem tren 95%,
50-95%, 5% en di 50% hay di 5% tong khoi u. (Hnh 15)
Hnh 15: Carcinom tuyen ai trang co o biet hoa tot (A); biet hoa va (B); biet hoa kem (C)
oi vi ung th khong biet hoa, th du nh carcinom khong biet hoa vom hau, co khi
khong phan biet noi nguyen uy cua ung th, tc la khong the xac nh c ay la 1 trng hp
carcinom, sarcom, limphom hay melanom, neu khong co cac ky thuat bo sung nh hoa mo
mien dch hoac knh hien vi ien t.(Hnh 16)
Benh ly U 65
Hnh 16: Carcinom khong biet hoa vom hau: nhuom HE thay cac am te bao nhan ln d dang (mui ten),
khong phan biet chac chan la carcinom hay limphom. Nhuom hoa mo mien dch thay cac am te bao nay
am tnh vi LCA nhng dng tnh vi cytokeratin; chng to ay la mot carcinom.
Cac u ac tnh c xep loai grad mo hoc (Histologic grade) e anh gia o ac tnh, u co
grad mo hoc cang cao th o ac tnh cang tang. Co nhieu he thong grad mo hoc khac nhau nh
he thong 4 grad mo hoc (grad I, II, II, IV), he thong 3 grad ( grad I, II, III) va he thong 2 grad
(grad thap va grad cao). Cac tieu chuan c dung e phan grad cung khac nhau tuy tng loai
u, v tr u va tuy theo tac gia, thng bao gom cac tieu chuan nh mat o te bao trong u, o biet
hoa te bao u, mc o a dang va d dang te bao, ch so phan bao, mc o hoai t trong u
Tren thc te, he thong 3

grad c s dung nhieu nhat
trong xep loai grad mo hoc, da
vao 2 tieu chuan chnh la o biet
hoa cua te bao u va ch so phan
bao trong khoi u; th du nh cach
xep loai grad mo hoc cua
carcinom te bao gai cua da theo
tac gia Warren. (Hnh 17)
Hnh 17: Carcinom te bao gai Grad I, co cau sng (mui ten, A); Grad II khong co cau sng nhng co cau
lien bao (mui ten, B); Grad III vi te bao u co bao tng ai toan, nhieu phan bao (mui ten, C), nhng khong
co cau sng va cau lien bao.
Benh ly U 66
Noi chung, viec xep loai grad mo hoc t nhieu mang tnh chu quan cua bac s giai phau
benh, v vay vai tro cua no trong viec anh gia tien lng benh th khong quan trong bang viec
xep giai oan ung th.
Bang sau ay tom tat cac iem khac biet chnh gia u lanh va u ac:
U LANH TNH U AC TNH
Toc o tang trng u cham nhanh

Biet hoa te bao u
+ Cau truc giong bnh thng thng t giong
+ Chc nang giong bnh thng mat hoac thay oi
ai the
+ Gii han ro khong ro
+ Vo boc co khong
+ Di ong tot kem / khong
+ Mat o chac cng / mem b
+ Mat cat thng ong nhat khong ong nhat
Vi the
+ Cau truc mo chu Giong mo lanh ao lon
+ Te bao bnh thng a dang, d dang, te bao khong lo
+ Nhan bnh thng a dang, to, tang sac, nhan quai, hach nhan to
+ T le N/BT bnh thng Cao
+ T le phan bao thap, phan bao bnh thng Cao, phan bao bat thng
Xam nhap Khong Co
Di can Khong Co
ap ng vi ieu tr khong tai phat sau cat bo de tai phat, gay t vong
IV. Qua trnh phat trien t nhien cua ung th (natural history):
Trong hn 200 loai ung th a c mo ta, co the noi moi loai eu co 1 qua trnh phat
trien t nhien rieng biet. Nhng nhn chung, qua trnh nao cung gom co 4 bc noi tiep nhau la:
S chuyen dang ac tnh cua mot te bao c the, s tang trng cua khoi u, s xam nhap tai cho
va s di can.
A/ S chuyen dang ac tnh:
Ung th c khi phat t mot te bao
c the (con goi la te bao soma) b ot bien gen
khong gay chet do tac ong cua cac yeu to t
moi trng ben ngoai (hoa chat, bc xa, virut)
hoac do t phat, mot so t trng hp do yeu
to di truyen. Ket qua te bao soma nay b
chuyen dang, tr nen co kha nang tang sinh
qua mc va t ong, tao thanh 1 dong te bao
u giong het nhau.
Tnh chat n dong cua khoi u a
c chng minh qua nghien cu u xay ra
cac phu n d hp t ve gen ma hoa cho
glucose-6-phosphat dehydrogenase (G6PD),
la gen nam tren nhanh dai cua nhiem sac the
X. Cac phu n nay co kieu gen la XAXB, moi
nhiem sac the X cha gen ma hoa cho 1
isoenzym, A hoac B, cua G6PD.
Ngay t rat sm trong thi ky phat
trien phoi (giai oan phoi nang), moi te bao
phoi se co hien tng bat hoat ngau nhien
mot trong 2 nhiem sac the X (tao thanh vat
Hinh 18: Tnh chat n dong cua u
Benh ly U 67
the gii tnh Barr), cho nen c the ngi phu n noi tren thc chat la mot the kham gom 2 loai
te bao soma vi t le bang nhau, moi loai ch bieu hien 1 loai isoenzym cua G6PD. Khi phu n
nay b 1 u c trn than t cung, ngi ta thay cac te bao u ch co bieu hien cua 1 trong 2 loai
isoenzym cua G6PD, chng to tat ca te bao cua u nay eu a c tao ra t cung 1 te bao
soma b chuyen dang ban au. (Hnh 18)
Te bao c the khi a chuyen dang ac tnh thanh te bao ung th se co kha nang tang
sinh t ong, khong con phu thuoc vao cac yeu to tang trng (YTTT) nh cac te bao bnh
thng na. Mot trong cac ly do la cac thu the oi vi YTTT tren be mat te bao u a b thay oi
khien no co the t kch thch ma khong can en YTTT hoac ban than te bao u co the t san
xuat ra cac YTTT can thiet cho s tang sinh cua chnh mnh (kch thch t tiet - autocrine
stimulation).
Trong moi trng nuoi cay, te bao bnh thng ch co the phan chia 1 so lan nhat nh
roi tr nen gia coi va chet, goi la a at en gii han Hayflick; trai lai, te bao u se phan chia mai
mai khi co ay u chat dinh dng, coi nh a tr nen bat t. Chung ta biet ac iem cau tao
cua phan t ADN va c che tai ban ADN te bao nhan thc (eukaryote) ch cho phep cac
nucleotid mi c gan them vao au 3 , v vay phan au mut cua nhiem sac the (telomere) se
b rut ngan t 50-100 cap baz sau moi lan phan bao. Tuy phan au mut cua moi nhiem sac the
co cha cac chuoi 6 nucleotid 5-TTAGGG-3 lap lai hang ngan lan, giup bao ve cac gen cha
ben trong phan t ADN nhng van khong ngan c s rut ngan ADN sau moi lan tai ban.
Chong lai s rut ngan nay la vai tro cua Telomerase, mot phc hp enzym ln co cha phan t
ARN moi cho phep phuc hoi phan ADN b rut ngan; enzym co hoat tnh manh cac te bao goc
hoac te bao mam sinh duc nhng hau nh khong con thay cac te bao a biet hoa.
Nh vay, gii han Hayflick tng ng vi s lao hoa cua cac te bao c the, do phan au
mut cua nhiem sac the a b bien mat hoan toan sau vai chuc lan phan bao, khien te bao mat
kha nang phan bao va chet. Te bao u bat t, co the phan chia mai mai v san xuat c enzym
telomerase, c che s rut ngan phan au mut nhiem sac the sau moi lan phan bao; thc vay,
trong 90% cac loai u cua ngi, ghi nhan co s gia tang hoat tnh cua telomerase, ieu nay m
ra 1 hng tiep can mi trong phng phap ieu tr nham ch. (Hnh 19).
Hnh 19: Vai tro cua enzym telomerase

Benh ly U 68
Cung trong moi trng nuoi cay, cac te bao bnh thng ch co the phan chia sau khi
a bam chac c len be mat cua mot gia va khi a sinh san thanh mot lp th ngng lai, do
co s kiem soat cua c che c che tiep can va c che c che mat o te bao (Hnh 20A). S
tang sinh cua te bao u th khong con chu s kiem soat nay, v vay chung co the sinh san chong
chat hon on len nhau ma chang can bam len 1 gia ; hn the na, chung con co the tach ri
nhau mot cach de dang do co nhng thay oi cau truc mang te bao lam giam o ket dnh. (Hnh
20B)
Hnh 20: Te bao bnh thng (A) va te bao ung th (B) trong moi trng nuoi cay.
Te bao u co the san xuat ra cac chat

giong nh te bao nguyen uy; th du te bao
ung th cua carcinom te bao gai da co the
san xuat ra chat keratin. Mot so loai te bao u
lai co the san xuat ra nhng chat khong thay
co te bao nguyen uy hoac ch co te bao
nguyen uy trong thi ky phoi thai; th du te bao
u cua ung th phoi loai te bao nho co the san
xuat ra ACTH, ADH, seretonin; te bao ung th
gan san xuat ra alpha fetoprotein AFP; te bao
ung th ruot san xuat ra khang nguyen
carcinom phoi CEA (carcinoembryonic
antigen). S san xuat nghch thng nay c
giai thch la do hien tng giai c che cac gen
(gene derepression) ma hoa cho cac protein
noi tren, von a b ong lai trong qua trnh
tang trng va biet hoa cua te bao (Hnh 21).
Tom lai, te bao c the mot khi a
chuyen dang ac tnh se co kha nang tang sinh
qua mc va t ong, thoat khoi s kiem soat
cua moi c che ieu hoa tang trng trong c
the.
Hnh 21: Te bao ung th gan san xuat AFP, te bao
ung th ruot san xuat CEA ( nhuom mau nau bang
ky thuat hoa mo mien dch)
Benh ly U 69
B/ S tang trng cua khoi u:
1. Toc o tang trng:
Toc o tang trng cua khoi u c bieu th bang thi gian nhan oi (TGN), la thi
gian can thiet e so lng te bao u tang gap oi.
V tat ca te bao trong u eu la con

chau cua mot te bao c the chuyen dang
ban au (ng knh khoang 10 m, nen
can phai qua 30 lan nhan oi e t te bao
ban au nay tao thanh 1 ty te bao, tng
ng vi 1 u co ng knh 1cm, nang 1
gram; la gii han nho nhat co the phat hien
c qua tham kham lam sang. T khoi u
nho nay, ch can them 10 lan nhan oi na
la co the at en trong lng 1kg, cha
1000 ty te bao; la gii han ln nhat ma c
the chap nhan c. (Hnh 22)
Hnh 22: Toc o tang trng cua khoi u
Thi gian tang sinh t te bao chuyen dang au tien en 1 khoi u phat hien c tren
lam sang c goi la thi ky tien lam sang; neu moi TGN la 3 ngay (bang vi chu ky te bao
bnh thng) th thi ky nay ch keo dai co 3 thang. Tat nhien tnh toan tren ch ung khi tat ca
cac te bao u eu cung hoat ong tang sinh va khong co te bao nao that thoat khoi khoi u;
nhng mot ieu chac chan ung va ang buon la khi phat hien c u tren lam sang th no a
tien c kha xa tren con ng phat trien t nhien cua mnh.
Tren thc te, thi ky tien lam sang thay oi rat khac nhau tuy loai ung th, khoang 3
thang oi vi ung th co o ac tnh cao nh limphom Burkitt (TGN= 3 ngay), 17 thang oi vi
sarcom Ewing (TGN= 17 ngay) hoac hang chuc nam oi vi carcinom tuyen ai trang
(TGN= 600 ngay). Noi chung, thi ky tien lam sang trung bnh cua a so cac loai ung th cua
ngi c c lng vao khoang 2 nam.
S khac nhau ve toc o tang trng (tc TGN) gia cac loai u la do khac biet ve phan
so tang trng va t le gia so lng te bao u mi c san sinh so vi so lng te bao b chet
hoac that thoat khoi khoi u.
Phan so tang trng la ty le te
bao ang hoat ong tang sinh trong
khoi u. Nghien cu cho thay phan so
nay ch cao trong giai oan au cua
qua trnh tang trng u, ngha la hau
het cac te bao u eu hoat ong tang
sinh; nhng sau o phan so tang
trng se giam dan v cang luc cang
co nhieu te bao u c biet hoa
khong con kha nang phan chia hoac
te bao dng lai ngh ngi giai oan
G0 hoac G1. V vay, vao thi iem
c phat hien tren lam sang; phan
Hnh 23: Phan so tang trng so tang trng cua a so ung th
thng khong vt qua 20%. (Hnh
23).
Benh ly U 70
Mat khac, co nhng te bao u b that thoat hoac chet do thieu nguon dinh dng, co
the lam thay oi moi can bang gia so lng te bao mi sinh ra tren so lng te bao mat i.
Cac loai ung th nh limphom, ung th phoi loai te bao nho co phan so tang trng cao (khoang
30%), so lng te bao mi sinh vt troi so te bao chet nen se co toc o phat trien nhanh. Trai
lai, cac ung th vu, ung th ruot gia co phan so tang trng thap (khoang 2-8%), so lng te
bao mi sinh ch hi troi hn so te bao chet nen toc o phat trien se cham hn.
2. S tang sinh mach mau trong khoi u:
S tang trng khoi u phu thuoc rat nhieu vao nguon dinh dng do mach mau a ti;
khong co phan bo mach mau, khoi u khong the co ng knh vt qua 1-2 mm (tng ng vi
gii han khuyech tan cua oxy va chat dinh dng t mach mau ra xung quanh).
Hnh 24: S tang sinh mach mau trong khoi u (A). Cay te bao carcinom tuyen ruot gia cua ngi vao mo
di da chuot, te bao ung th phat trien thanh 1 u ghep; s tang sinh mach mau giup u gia tang kch thc
ro ret ch sau 20 ngay (B).
Chnh v vay, ban than te bao u thng co kha nang tiet ra nhieu yeu to tao mach khac
nhau nh yeu to tang trng nguyen bao si FGF (Fibroblast growth factor), yeu to tang trng
noi mo mach mau VEGF (vascular endothelial growth factor); e kch thch s tang sinh mach
mau trong khoi u (Hnh 24).
S tang sinh mach mau co 1 tac ong kep oi vi s tang trng khoi u:
- Mach mau tang sinh cung cap oxy va chat dinh dng can thiet cho hoat ong tang
sinh cua u.
- Te bao noi mo cua mach mau mi thanh lap, lai tiep tuc tiet ra cac yeu to tang
trng kch thch s tang trng khoi u.
Mat khac, s tang sinh mach mau trong khoi u cang lam tang kha nang di can xa oi vi
1 so loai ung th nh melanom, ung th vu, ung th phoi.
3. S a dang hoa te bao u:
Thc te cho thay co nhieu ung th tr nen ac tnh hn sau mot thi gian tien trien. HIen
tng nay c giai thch la do tnh khong on nh ve mat di truyen cua cac te bao u khien
chung de b them nhieu ot bien mi mot cach t phat trong qua trnh tang sinh. Cac ot bien
mi nay co loai gay chet te bao u nhng cung co loai lam te bao u co kha nang song sot cao
hn hoac tr nen ac tnh hn. Nh vay qua trnh tang trng u cung la qua trnh tch luy va chon
loc ot bien; lam xuat hien them nhieu tieu dong te bao u khac nhau vi nhng thuoc tnh sinh
Benh ly U 71
hoc mi nh t can yeu to tang trng hn, kha nang xam lan va di can manh hn, kha nang
khang thuoc cao hn. Tom lai, u khi au co tnh n dong nhng khi c phat hien tren lam
sang th co the noi no a c cau tao bi nhng thanh phan te bao rat a dang ve mat sinh
hoc. (Hnh 25)
Hnh 25: S a dang hoa te bao u.
C/ S xam nhap tai cho (local invasion)

Kha nang xam nhap tai cho va di can xa la 2 ac trng rieng biet cua ung th, khong
bao gi thay u lanh.
Ung th thng phat trien tai cho trong 1 thi gian kha lau nhng kho phat hien v u con
qua nho, cha xam lan pha huy mo lan can; noi cach khac, ung th con trong thi ky tien lam
sang. Th du trong carcinom te bao gai co t cung, cac te bao ung th co the con gii han trong
lp bieu mo cha xam nhap qua mang ay trong hang chuc nam ma khong gay ra trieu chng
g ang ke; giai oan nay c goi la carcinom tai cho. Khi co bieu hien trieu chng tren lam
sang th ung th thng a tien trien qua giai oan xam nhap va di can (Hnh 13). Hien nay
ngi ta nhan manh nhieu en cac chng trnh tam soat nham phat hien sm ung th ngay
trong thi ky tien lam sang, e tang kha nang cha khoi va giam thieu t le t vong do ung th
a bc vao giai oan xam nhap va di can.
Ung th uc xac nh a tien trien qua giai oan xam nhap khi no khong con gii han
trong mo nguyen uy va bat au xam nhap vao mo lanh lan can. Hau qua cua s xam nhap rat
khac nhau tuy theo loai mo hoc va v tr cua ung th, co khi rat nang ne e doa en tnh mang
benh nhan. Th du:
- Ung th co t cung xam nhap vao am ao va vung chu cung, gay tac nghen nieu
quan.
- Carcinom ong tuyen vu xam nhap gay l loet da vu, tut num vu.
- Carcinom tuyen tuy xam nhap vao am roi than kinh giao cam than tang (celiac
plexus) gay au bung d doi.
Giai thch ve c che cua hien tng xam nhap oi vi cac loai carcinom; chung ta biet
trong c the bnh thng, cac cau truc bieu mo c phan cach nhau bang chat nen ngoai bao
gom co 2 thanh phan la mang ay va mo lien ket ke. V vay e tien trien t giai oan ung th tai
cho sang giai oan xam nhap, cac te bao u phai thc hien 4 bc sau (Hnh 26):
1. S tach ri cac te bao u: cac te bao bieu mo bnh thng c lien ket vi nhau chat
che nh vao cac the lien ket te bao (desmosome) va cac phan t ket dnh co tren be mat (th du
nh E- cadherin). cac te bao ung th, co s thay oi cau truc mang lam mat i cac phan t
ket dnh khien chung de bong ri nhau hn.
Benh ly U 72
2. Pha huy chat nen ngoai bao: te bao ung th che tiet ra cac enzym
metalloproteinase (gelatinase, collagenase, stromelysin) cat t cac si collagen typ IV va
laminin, lam phan huy mang ay, tao ra cac lo thung.
3. Gan ket mi: cac si collagen typ IV va laminin b cat t bc 2 se e lo ra cac v
tr gan ket mi tng ng vi cac thu the co tren be mat te bao ung th. Cac moi gan ket mi
nay se thuc ay te bao ung th di chuyen.
4. Di chuyen trong chat nen ngoai bao: te bao ung th chui qua lo thung tren mang
ay i vao mo lien ket ke. Tai ay, te bao ung th lai tiep tuc hoat ong gan ket (th du vi
fibronectin), phan huy cac thanh phan cua chat nen ngoai bao va di chuyen. S di chuyen cua
cac te bao ung th co the c kch thch bi chnh cac chat do chung tiet ra, th du nh cac yeu
to di chuyen t tiet AMF (autocrine motility factor) ma te bao ung th co thu the tng ng.
Hnh 26: C che cua hien tng xam nhap
D/ S di can
Di can la thuat ng dung e mo ta s hnh thanh nhng o ung th th phat nam cach xa
khoi ung th nguyen phat, do s phat tan cac te bao u t khoi ung th nguyen phat. Cau tao vi
the cua u th phat phan ln eu giong vi u nguyen phat. Khoang 30 - 50% benh nhan ung th
khi c phat hien th a co bieu hien di can ro ret.
Moi loai ung th eu co the cho di can nhng kha nang di can cua chung khong ong
eu nhau. Th du carcinom te bao ay cua da hiem khi cho di can xa trong khi sarcom xng th
lai cho di can xa rat sm.
Cac ung th co the cho di can theo 3 ng sau:
1. ng mach bach huyet :

Te bao ung th xam nhap vao mach bach huyet i en cac hach. ay la ng di can
trc tien thng thay oi vi cac carcinom; trong khi o sarcom lai rat hiem khi cho di can theo
ng bach huyet. Kieu phan bo cac hach di can cua moi loai ung th thay oi tuy theo v tr
cua khoi u nguyen phat va he thong dan lu mach bach huyet t nhien tai o. Th du: carcinom
ong tuyen vu v tr 1/4 tren ngoai vu thng cho di can trc tien en hach nach cung ben
(Hnh 27A). Ung th co t cung cho di can en hach chau. Ung th dng vat cho di can en
Benh ly U 73
hach ben. Ung th phoi cho di can en cac hach canh phe quan, roi en hach ron phoi va
hach trung that.
S hnh thanh cac o ung th th phat trong hach lam cac hach sng to, cng, dnh nhau
thanh khoi. Ve mat vi the, cac o ung th th phat co cau tao tng t u nguyen phat, c hnh
thanh trc tien trong xoang di vo, sau o se xam lan sau vao trong va cuoi cung co the pha
huy toan bo nhu mo hach. (Hinh 27B)
Hnh 27: Carcinom ong tuyen vu di can hach nach cung ben (A); cac o ung th th phat (*) c thay
trc tien xoang di vo cua hach, tang sinh pha huy dan nhu mo hach (B).
Co nhng trng hp ac biet goi la di

can cach quang (skip metastases), cac te
bao ung th khong tao ra o th phat trong
hach au tien ma chung en, nhng tiep tuc
di chuyen theo dong bach huyet e tao o th
phat trong nhng hach tiep sau o. Cung co
nhng trng hp goi la di can ngc, te
bao ung th t o th phat trong 1 hach a b
di can se di chuyen ngc dong bach huyet
e tao ra 1 o th phat khac trong hach
pha trc. (Hnh 28)
Sau cung, te bao ung th co the vt
Hnh 28: Te bao ung th di can en hach theo ng
bach huyet (A); oi khi di can ngc dong (B).
qua tat ca he thong bach huyet, theo ong
ngc o vao he tuan hoan e tao ra o ung
th th phat theo ng mau.
2. ng mau:
La ng di can trc tien thng gap cac sarcom; cac carcinom thng cho di can
hach trc roi sau o mi di can theo ng mau nh vao nhng thong noi t nhien gia he
thong mach bach huyet va he thong mach mau, hoac do ban than te bao ung th trc tiep xam
nhap vao mach mau (tuy nhien trong mot so trng hp, di can theo ng mau cua carcinom
co khi con c thay trc ca di can hach). Te bao ung th xam nhap pha huy thanh cac tnh
mach (ong mach t b hn do co thanh day), chui vao dong mau phat tan i khap ni trong c
the. Cac o ung th th phat do di can theo ng mau thng thay nhat gan va phoi; bi v
gan la ni tiep nhan mau cua toan bo he tnh mach ca con phoi la ni tiep nhan mau cua he
tnh mach chu (Hnh 28).
Cac o ung th nguyen phat nam gan cot song (ung th tuyen giap, ung th tuyen tien
liet ) thng cho di can theo mang tnh mach canh song, tao ra cac o th phat tai cac xng ot
song. Nh vay t nhieu cung co the d oan c kieu phan bo giai phau hoc cua cac ung th
th phat trong c the, da vao v tr cua ung th nguyen phat va s dan lu tnh mach tai o.
Tuy nhien neu ch n gian nh the th kho ma giai thch c kieu di can xa cua nhieu loai ung
Benh ly U 74
th; th du nh ung th phoi thng cho di can en tuyen thng than va nao; ung th vu hay
cho di can en xng, ung th tuyen giap lai hay cho di can en da va mo mem. Ngc lai cung
co nhng mo-c quan hau nh khong bao gi b di can nh c van, c tim, lach. Co the a co
mot c che chon loc - hng c quan khac nhau tuy tng loai ung th va tng benh nhan trong
viec hnh thanh cac o ung th th phat do di can theo ng mau.
Hnh 28: Ton thng di can phoi gom nhieu o (A); tren vi the la cac am tuyen ung th xam nhap nhu mo
phoi (B); di can gan a o (C); vi the cho thay cac am tuyen ung th xam nhap vao mo gan (D).
Cung can nhan manh la khong phai moi te bao ung th sau khi lot vao dong mau eu
tao ra c cac o ung th th phat. Nghien cu tren chuot cho thay mac du moi ngay co hang
trieu te bao t khoi ung th nguyen phat lot vao dong mau nhng ch co vai o ung th th phat
c hnh thanh. Ngi ta c lng co khong qua 1/1000 so te bao ung th lot vao dong mau
la co kha nang tao ra c o ung th th phat.
3. ng ong t nhien:
Cac ung th co the mn ng ong t nhien nh khoang mang bung, khoang mang
phoi; e di can en cac ni khac trong c the. Th du:
- Carcinom tuyen ai trang co the xam nhap qua thanh ruot, tao ra cac o th phat trong
khoang mang bung cach xa v tr nguyen phat.
- Ung th phoi xam nhap qua mang phoi, tao ra cac o th phat trong khoang mang phoi.
- Ung th buong trng gieo rac vao trong khoang mang bung, tao cac o th phat tai mac
noi, mac treo ruot. (Hnh 29)
- Ung th nao mn ng nao that en mang nao.
Ngoai ra, ngi ta con e cap en 1 con ng di can nhan tao, xay ra do s gieo rac
cac te bao ung th dnh vao dao mo, gang tay trong khi mo.
Benh ly U 75
Hnh 29: ai the va vi the cua ung th buong trng di can mac noi theo ng khoang mang bung
4. Ung th di can khong ro o nguyen phat:

Khoang 4% benh nhan ung th ch co bieu hien di can ma o nguyen phat th khong thay
ro. Tien lng cac trng hp ch cho di can hach th tot hn so vi trng hp co di can ni
khac, nhng cung ch 1/4 trong so nay la co ap ng vi ieu tr. Nhng trng hp di can
khong ro o nguyen phat gay kho khan cho ca thay thuoc lan benh nhan v phai lam nhieu xet
nghiem e tm o nguyen phat. Bang di ay gi y v tr ung th nguyen phat can tm tng ng
vi cac bieu hien di can khac nhau:
Bieu hien di can V tr ung th nguyen phat co the gap
Hach bach huyet:

Co tren va gia Vung au co
Co di va tren on
Ben phai Phoi, vu
Ben trai ng tieu hoa, phoi, vu
Nach Vu, chi tren, da day
Ben Chi di, am ho, hau mon-trc trang, bang quang, tuyen tien liet
Da Phoi, vu, than, buong trng, melanom

Chi tren Than
Bung, chi di ai trang, bang quang
Ron Da day, tuyen tu , ai trang
Nao Phoi, vu, melanom
Phoi Phoi, vu, tieu hoa, sinh duc
Mang phoi Phoi, vu, da day, tuyen tuy, gan
Mang tim Phoi, vu, limphom, melanom
Gan Tuyen tuy, da day, ai trang, phoi, vu
Co trng Buong trng, tuyen tuy, da day, ai trang
Tuy xng Vu, phoi, tuyen tien liet, tuyen giap
Xng
Ton thng tieu xng a u tuy, vu, phoi, tuyen giap
Ton thng tao xng Tuyen tien liet, sarcom, carcinoid, benh hodgkin, phoi
Hon hp Vu
Chen ep tuy song Phoi, vu, tuyen tien liet, than, tieu hoa, sarcom, limphom, a u tuy
Vung ngc Vu, phoi
Vung bung Limphom, tuyen tien liet
Viem tac tnh mach di chuyen Tuyen tuy, phoi, tieu hoa
Benh ly U 76
C che cua hien tng di can theo ng bach huyet hoac ng mau th cung tng
t nh hien tng xam nhap. Cac te bao ung th di chuyen trong chat nen ngoai bao phai en
gan ket vao mang ay bao quanh cac tnh mach va mach bach huyet roi pha huy no e chui
vao long mach. Trong long mach, ai a so cac te bao ung th di chuyen rieng re nhng cung
co the ket dnh vi cac tieu cau va bach cau tao thanh mot cuc huyet tac ung th. Khi di chuyen
en vung thch hp, te bao ung th ket dnh len te bao noi mo, pha huy mang ay, chui ra khoi
long mach va tang sinh thanh mot khoi u th phat. (Hnh 30)
Hnh 30: C che cua hien tng di can
V. Dch te hoc ung th (cancer epidemiology):

La mon hoc nghien cu ve s phan bo ung th trong 1 quan the dan c va nhng yeu
to co lien quan nh tuoi tac, nghe nghiep, chung toc, van hoa, tap quan...
Nghien cu dch te ung th cung cap nhng thong tin rat gia tr, gop phan lam sang to
nguyen nhan sinh ung, th du nh qua ieu tra dch te hoc co the chng minh moi lien he nhan
qua gia thoi quen hut thuoc la va ung th phoi, xuat o ung th phoi gia tang t le thuan vi so
ieu thuoc hut moi ngay.
Sau ay la 1 so yeu to thng c khao sat trong cac nghien cu dch te hoc ung th.
1. Xuat o ung th:
La so trng hp ung th mi xuat hien trong quan the dan c hang nam, tnh tren
100.000 dan.
Theo To chc Y te the gii (WHO), nam 2008 c tnh tren toan the gii co khoang 12,5
trieu trng hp ung th mi va gan 7,5 trieu trng hp t vong do ung th; d oan en 2020
moi nam se co 16 trieu trng hp ung th mi va 10 trieu trng hp t vong.
My, xuat o ung th la vao khoang 523 trng hp/ 100.000 dan/ nam; c lng
trong nam 2012 co 1.638.910 trieu trng hp ung th mi va 577.190 trng hp t vong do
ung th. Ph ton danh cho ung th tai My vao nam 2007 a len en 226 ty o la.
nc ta, theo so lieu cua Bo Y te (2002) th moi nam co khoang 150.000 trng hp
ung th mi va 100.000 trng hp t vong; tng ng vi 1 xuat o ung th vao khoang 180 -
190 trng hp/100.000 dan/ nam.
So sanh gia cac nuc cong nghiep phat trien va cac nc ang phat trien ve xuat o
cua 10 loai ung th thng gap nhat (To chc nghien cu ung th quoc te IARC, 2008), ta
thay co s lien quan gia mot so loai ung th vi trnh o phat trien cua cac quoc gia. Th du:
Benh ly U 77
Ung th tuyen tien liet

ng hang th 1 cac nc
phat trien nhng ch ng hang
th 8 cac nc ang phat
trien; trai lai, ung th gan va ung
th co t cung van con la ung
th pho bien nhng nc
ngheo, ng hang th 4 va 6, so
vi hang th 8 va 9 cac nc
giau. (Hnh 31).
Hnh 31 : So sanh xuat o chuan

theo tuoi cua 10 loai ung th thng
gap gia 2 nhom nc.
Gia nhng vung khac nhau trong cung mot quoc gia, cung co the thay s khac biet ve
xuat o cua cac loai ung th thng gap. So sanh gia thanh pho Ho ch Minh va Ha noi trong
khoang thi gian 5 nam t 2004 en 2008, ta thay 4 loai ung th thng gap nhat gii nam
eu la ung th phoi, gan, ruot gia va da day; gii n, ung th hang au eu la ung th vu
nhng xuat o Ha noi cao gan gap oi, ung th co t cung con chiem v tr th 2 thanh pho
Ho ch Minh trong khi ch ng hang th 5 Ha noi. Tm hieu nguyen nhan gay ra nhng khac
biet nay co the giup e ra nhng bien phap phong chong ung th tot hn cho moi cong ong
dan c.(Hnh 32 )
Hnh 32: So sanh xuat o 10 loai ung th thng gap gia thanh pho Ho ch Minh va Ha noi
2. Yeu to a d:
Co s khac biet ve xuat o cua nhieu loai ung th gia nhng vung a d khac nhau.
e ly giai s khac biet nay la do anh hng cua yeu to chung toc hoac do yeu to moi trng,
ngi ta thng tien hanh nghien cu tren nhng nhom ngi di dan nhap c. Th du:
- Nhat, ung th da day co xuat o cao nhat, nhieu hn My gap 10 lan. Nhng trong
cac gia nh ngi Nhat nhap c vao My, cac the he con chau lai co xuat o ung th da day
thap nh dan ban x. Nh vay xuat o ung th da day cao tai Nhat co le la do cac yeu to moi
trng (che o an nhieu gia v ?) hn la do yeu to chung toc.
- Phu n cac nc Bac My co xuat o ung th vu cao nhat, nhieu hn phu n Chau A t
2-3 lan, co le do che o an nhieu m, sinh con t va muon.
- Ung th gan tng oi hiem gap My nhng kha pho bien cac nc ong Nam A,
co le lien quan vi tnh trang viem gan sieu vi B va thc pham nhiem Aflatoxin thng thay tai
vung nay.
Benh ly U 78
3. Tuoi:
Khoang 77% cac trng hp carcinom xay ra sau 55 tuoi. Ghi nhan ung th tai benh
vien ung bu cho thay xuat o cac ung th hang au ca 2 gii bat au tang nhanh sau 40
tuoi. S gia tang xuat o ung th theo tuoi tac c xem la hau qua cua s tch luy theo thi
gian cac ot bien te bao soma di tac ong cua cac yeu to sinh ung trong moi trng. Bang
sau ay cho thay nguy c b ung th tang dan theo tuoi tac.
Nguy c b ung th
o tuoi Nam gii N gii
Mi sinh - 39 1/58 1/52
40 - 59 1/13 1/11
60 - 79 1/3 1/4
Tuy nhien cung co nhng loai ung th hay xay ra tre em di 5 tuoi nh benh bach
cau nguyen bao limpho, u nguyen bao vong mac, u nguyen bao than kinh, u Wilms, sarcom c
van...
4. Nghe nghiep:
Percival Pott la ngi au tien vao nam 1775, ghi nhan s gia tang xuat o ung th da
bu nhng ngi th cao ong khoi, t o a ra gia thiet bo hong la thu pham gay ung th
nay. Ngay nay a xac nh tac nhan sinh u trong bo hong chnh la cac hydrocarbon thm a
vong.
Ung th co t cung co xuat o cao nhng cong nhan tnh duc nhng lai rat hiem gap
n tu s, chng to nguyen nhan gay ung th co the la 1 yeu to c lay truyen qua ng sinh
hoat tnh duc ma ngay nay a xac nh c la cac virut HPV (human papillomavirus).
5. Di truyen:
Trong hn 200 loai ung th a c biet, ai a so la do cac ot bien gen xay ra t phat
hoac do tac ong cua cac yeu to moi trng; ch co khoang 5-10% trng hp la co vai tro cua
yeu to di truyen vi nhng mc o khac nhau nh ung th di truyen, benh di truyen lam cho c
a ngi benh de b ung th va ung th co tnh gia nh.
a/ Ung th di truyen: cho en nay a xac nh c hn 30 loai ung th la benh di

truyen theo kieu gen troi-nhiem sac the thng. Th du:
* U nguyen bao vong mac (Hnh 33):
Hnh 33: U nguyen bao vong mac mat phai lam ong t co anh xam trang (A); do u phat trien t vong mac
xam lan vao the thuy tinh (B); tren vi the, te bao u hnh tru thap, nhan lech ay, xep thanh cac cau truc hoa
hong (C).
La 1 ung th tre em hiem gap, xuat o ch vao khoang 1/30.000 tre sinh song, gom 2
the benh: the le te (60%) va the di truyen (40% cac trng hp). Trong the di truyen, tre mang
Benh ly U 79
gen benh co nguy c b u cao gap 10.000 lan so vi tre bnh thng; u thng xuat hien ca
2 mat, khac vi the le te thng ch 1 mat. Hien nay chung ta a biet c che sinh ung la do
ot bien gen Rb, nam tren nhanh dai nhiem sac the 13.
* Benh polyp tuyen ai trang co tnh gia nh (familial adenomatous polyposis) : chiem t
le khong qua 1% ung th ai trc trang. Ngi mang gen benh se co hang tram polyp tuyen
ai - trc trang vao o tuoi 30; en tuoi 50, mot so polyp nay se tien trien thanh carcinom tuyen.
C che sinh ung ot bien gen APC, nam tren nhanh dai nhiem sac the so 5.
b/ C a di truyen de b ung th: co mot so benh di truyen theo kieu gen lan- nhiem
sac the thng tuy khong phai la benh ung th nhng ngi mang gen benh trang thai ong
hp t se co c a de b ung th hn ngi bnh thng. Th du:
* Benh kho b sac to (xeroderma pigmentosum): ca the ong hp t ve gen nay de b
melanom ac va cac loai ung th da khac do tac ong cua bc xa cc tm co trong anh sang
mat tri.
c/ Ung th co tnh gia nh: trong 1 so gia nh, oi khi co s xuat hien trung hp 2 - 3
thanh vien b cung mot loai ung th nh ung th vu, ung th buong trng, ung th ai trc trang,
ung th tuyen giap...ma kieu di truyen khong the hien ro troi hay lan. Nguyen nhan cua nhng
trng hp nay co the la do s lu truyen trong dong ho mot vai loai ot bien gen nao o, khien
cho cac thanh vien co nguy c mac ung th cao hn ngi bnh thng t 2-3 lan.
6. Cac ton thng tien ung:
La nhng ton thng co nguy c cao chuyen thanh ung th nhng khong tat yeu xay ra
nh vay. Th du:
* Ton thng sa cha tai tao keo dai: cac vet loet da khong lanh, lo do da man tnh co
the chuyen thanh carcinom te bao gai; viem gan man co the chuyen thanh ung th gan.
* Tang san khong ien hnh va nghch san: Tang san khong ien hnh noi mac t cung
co the chuyen thanh ung th noi mac t cung; tang san khong ien hnh bieu mo ong tuyen vu
co the chuyen thanh carcinom ong tuyen vu; nghch san bieu mo co t cung co the chuyen
thanh ung th co t cung; nghch san bieu mo ho hap do hut thuoc la co the chuyen thanh ung
th phe quan; nghch san bieu mo tieu hoa trong viem loet ai trang man tnh co the chuyen
thanh carcinom ai- trc trang.
* Ton thng bach san niem mac mieng, dng vat va am ho co the chuyen thanh
carcinom te bao gai.
VI. Nguyen nhan gay ung th:

Cac tac nhan sinh ung c xep vao 3 nhom chnh: cac hoa chat, bc xa va virut.
Chung co the tac ong rieng re hoac hiep ong vi nhau.
A. Cac hoa chat sinh ung (chemical carcinogen):
Cac hoa chat sinh ung co cau tao rat a dang, co nguon goc t nhien hoac nhan tao.
ac iem chung cua cac hoa chat sinh ung la chung co ai lc ien t rat cao, de dang tng
tac vi cac phan t protein, ARN va ADN. V vay, hau het cac hoa chat sinh ung cung la nhng
tac nhan gay ot bien (mutagen), co the gay ton thng cho phan t ADN. Phan biet 2 loai hoa
chat sinh ung:
- Hoa chat sinh ung trc tiep: co kha nang trc tiep gay ton thng phan t ADN, tao
ra ung th. Th du cac chat alkyl hoa. ang chu y la mot so chat alkyl hoa nh
cyclophosphamide, chlorambucil a c s dung thanh cong trong ieu tr mot so loai ung th
(ung th buong trng, limphom) th lai co kha nang gay ra mot ung th mi ve sau (thng la
benh bach cau).
Benh ly U 80
- Hoa chat sinh ung gian tiep: a so cac hoa chat sinh ung thuoc ve loai nay, ban
than chung cha phai la cac tac nhan sinh ung, can phai c chuyen hoa trong c the e tr
thanh mot tac nhan sinh ung thc s. Th du:
* Cac hydrocarbon thm a vong co trong dau mo ( benzanthracene), trong khoi thuoc
(benzopyrene); khi vao c the c chuyen hoa thanh epoxide, co kha nang tao lien ket hoa tr
vi ADN, lam ot bien gen , gay ra ung th da va ung th phoi. (Hinh 34)
Hnh 34 : C che sinh ung cua hydrocarbon thm va aflatoxin
* Cac amin thm va pham nhuom nhom azo: th du chat beta naphthylamine, mot amin
thm c s dung nhieu trong cac x nghiep che bien cao su; cac pham nhuom nhom azo
c dung e nhuom mau thc pham trong cho ep mat. Cac chat nay khi vao c the se c
chuyen hoa tai gan, tr thanh tac nhan sinh ung thc s, co the gay ra ung th gan va ung th
bang quang.
* Nitrosamin: nitrat c s dung lam phan bon, chat bao quan thc pham; khi vao c
the, chung c chuyen hoa bi cac vi khuan thng tru tai ruot, ket hp vi amin thanh
nitrosamin. Nitrosamin la mot tac nhan sinh ung thc s, co kha nang gay ra cac ung th ng
tieu hoa.
* Aflatoxin: la san pham cua Aspergillus flavus, mot loai nam moc phat trien manh tren
thc pham ngu coc bao quan kem. Trong c the, aflatoxin c chuyen hoa thanh epoxide, la
tac nhan sinh ung manh, co the gay ra ung th gan.
* Cac hp chat co cha arsenic co kha nang gay ung th da; cac thuoc bao ve thc vat
co the gay ung th gan.
Mot iem can nhan manh la khong phai moi ton thng ADN do tac ong cua cac hoa
chat sinh ung eu dan en ung th, bi v te bao van co kha nang sa cha mot so loai ton
thng ADN; khong vay th xuat o ung th do hoa chat han a tang vot.
B. Cac bc xa (radiation)
Nang lng bc xa, hoac di dang tia cc tm cua anh sang mat tri, hoac di dang
cac bc xa ion hoa, eu co the gay chuyen dang te bao nuoi cay, lam phat sinh ung th ngi
va cac ong vat th nghiem.
1. Tia cc tm:
Tia cc tm co trong anh sang mat tri c chia thanh 3 loai theo o dai song: UVA
(320-400nm), UVB (280 320nm) va UVC (200 280nm). UVB c xem la tac nhan chnh co
the gay ra nhieu loai ung th da khac nhau nh melanom, carcinom te bao gai, carcinom te bao
ay; ngi da trang co nguy c mac benh cao hn ngi da mau do thieu tac ong bao ve cua
sac to melanin trong lp bieu b (giup hap thu tia cc tm). UVC cung co kha nang sinh ung
nhng rat may la no a c chan gan het bi tang ozon bao quanh trai at; v vay s huy hoai
tang ozon nh hien nay do cac kh thai t mat at (nh chat lam lanh chlorofluorocarbon) co kha
nang lam tang so trng hp ung th da trong tng lai.
Benh ly U 81
Hnh 35 : C che sinh ung cua tia cc tm
C che sinh ung cua tia cc tm la do tac ong cua no tren phan t ADN, tao cau noi
gia cac baz pyrimidin. Neu nhng ton thng ADN nay khong c sa cha kp thi, ot bien
gen co the xay ra va dan en ung th. (Hnh 35)
2. Bc xa ion hoa:
Gom co 2 dang: cac song ien t (tia X, tia gamma) va cac hat mang ien tch hoac co
nang lng cao (hat alpha, hat beta, proton, neutron). Tat ca eu co kha nang sinh ung nh a
c thay qua s gia tang xuat o cua nhieu loai ung th nhng nan nhan song sot sau 2 vu
no bom nguyen t tai Nhat ban nam 1945 va vu no nha may ien hat nhan Tchernobyl tai Lien
xo nam 1986.
Cong nhan khai thac mo uranium cung co xuat o ung th phoi cao gap 10 lan ngi
bnh thng. Ngay ca nhng lieu phong xa dung trong tr lieu cung co the gay ung th neu
khong c ch nh ung; th du co 9% so tre em a tng c chieu xa vao vung co ngc khi
con be ve sau se b ung th tuyen giap.
Co mot s khac biet ve o nhay cam gia cac mo c the oi vi tac ong sinh ung cua
cac bc xa ion hoa. Cac mo ac biet nhay cam gom co mo tao huyet, tuyen giap, tuyen mang
tai, vu, phoi; trai lai, da, xng, ong tieu hoa th tng oi t nhay cam hn.
C che sinh ung cua cac bc xa ion hoa la do chung co kha nang gay ra ot bien gen
va cac roi loan cau truc nhiem sac the.
C. Cac virut sinh u (oncogenic virus):

Tren ong vat th nghiem, ngi ta a chng minh kha nang sinh u cua hang tram loai
virut ARN va ADN khac nhau, nhng en nay cung ch mi co vai loai virut c xac nhan la co
kha nang sinh u ngi. Du sao th s nghien cu ve cac virut sinh u ong vat a giup kham
pha s ton tai cua cac gen sinh u (oncogen) va lam gia tang mc hieu biet ve c che sinh ung
mc o phan t.
1. Virut ARN sinh u:

Tat ca cac virut ARN sinh u eu thuoc ve ho Retrovirus, ngha la chung co cha enzym
sao chep ngc (reverse transcriptase), cho phep sao chep ARN cua virut thanh ADN (Hnh
29A). Cau tao di truyen cua Retrovirus la mot mach n ARN, co cha cac gen pol ma hoa cho
enzym sao chep ngc, gen gag ma hoa cho protein capsid va gen env ma hoa cho protein vo
bao; ngoai ra ve pha hai au 3 va 5 con co 2 oan LTR ( Long terminal repeats) dai khoang
250-1200 nucleotid, cha cac yeu to ieu hoa can thiet cho hoat ong cua retrovirus nh to hp
gen vao bo gen te bao chu, tong hp protein. (Hnh 36, 37)
Benh ly U 82
Hnh 37:
Hnh 36: Vong i cua cac Retrovirus Bo gen cua Retrovirus (B)
Tuy theo kha nang gay chuyen dang cac te bao ong vat nuoi cay nhanh hay cham
(sau vai tuan hoac vai thang), virut ARN sinh u c phan thanh 2 loai: (Hnh 38)
a. Virut ARN sinh u gay chuyen dang nhanh (Acute transforming oncogenic RNA
virus):
Kha nang gay chuyen dang nhanh cua cac virut nay la do bo gen cua chung co cha
cac gen gay chuyen dang, goi la gen virut sinh u, hoac oncogen-virut (viral oncogene), viet tat
la v-onc (Hnh 31). Th du: v-sis la oncogen cua retrovirus gay sarcom kh (simian sarcoma
virus), v-fes la oncogen cua retrovirus gay sarcom loai meo (feline sarcoma virus) . Cau tao
cua bo gen cac retrovirus nay eu gom co cac gen env, v-onc, gag va 2 oan LTR 2 au.
Nhng loai retrovirus khong gay chuyen dang th khong cha cac oncogen trong bo gen cua
chung.
Hnh 38: Bo gen cua Retrovirus sinh u
Cac phan t protein ma hoa bi oncogen c tong hp, goi la oncoprotein, co kha nang
chuyen dang te bao nuoi cay thanh te bao ung th; v vay con c goi la yeu to chuyen dang
(transforming factor) (Hnh 39).
Benh ly U 83
Hnh 39: C che sinh u cua 2 loai Retrovirus gay chuyen dang
Bang ky thuat lai ghep phan t (molecular hybridization), ngi ta rat ngac nhien khi
phat hien trong ADN cua te bao ngi bnh thng cung co cha cac gen tng t vi oncogen
virut; cac gen nay c goi la tien-oncogen (proto-oncogene); th du tien-oncogen tng t v-
sis c goi la sis, c tm thay tren nhiem sac the 22, tien-oncogen tng t v-fes la fes nam
tren nhiem sac the 15.
Cac tien-oncogen cung c tm thay hau het cac loai sinh vat, t sinh vat cap thap
cho en loai ngi. S bao ton cac gen nay trong suot qua trnh tien hoa chng to cac tien-
oncogen rat can thiet cho s tang trng va biet hoa cua te bao bnh thng. Khi cau truc tien-
oncogen b thay oi hoac khi s bieu hien cua no lech lac, tien-oncogen c hoat hoa thanh
oncogen-te bao, viet tat la c-onc (cellular oncogen), co the gay roi loan tang sinh te bao, dan
en s hnh thanh u.
Da vao phat hien tren, ngi ta cho rang cac retrovirus sinh u gay chuyen dang nhanh
khi au co cau tao bo gen giong cac retrovirus khong gay chuyen dang khac, ngha la khong
co cha cac v-onc. Cac v-onc nay la ket qua cua s tai to hp ngau nhien gia bo gen cua virut
va ADN cua te bao chu bnh thng, nh o cac tien-oncogen trong bo gen cua te bao chu
c chuyen sang bo gen cua virut va bien thanh cac v-onc.
b. Virut ARN sinh u gay chuyen dang cham (Slow transforming oncogenic RNA virus):
Loai virut nay khong cha cac v-onc; sau khi xam nhap vao te bao nuoi cay, toan bo bo
gen cua virut c sao chep ngc thanh ADN goi la tien virut (provirus) va c to hp ngau
nhien vao bo gen cua te bao chu. Neu tien virut ngau nhien c gan ket gan vi mot tien-
oncogen th di tac dung cua yeu to ieu hoa nam trong chuoi LTR cua tien virut, tien-oncogen
cua te bao chu co the b hoat hoa thanh oncogen-te bao, a en s chuyen dang te bao. Do
tnh chat ngau nhien nay ma phai mat vai thang mi co tac ong gay chuyen dang.
Mac du tren ong vat thc nghiem, a phat hien c nhieu loai retrovirus co kha nang
sinh u; nhng oi vi ngi th ch mi xac nh c 1 loai retrovirus co kha nang gay ung th
la virut HTLV-1 (human T-cell leukemia virus type 1), gay ra benh bach cau te bao T typ 1. ay
la benh thng gap mot so vung cua Nhat ban va vnh Caribe. Virut HTLV-1 sau khi xam
nhap vao ngi se tan cong va gay chuyen dang cac limpho bao T CD4+; 1% so ngi nhiem
virut se phat benh bach cau n dong te bao T sau thi gian tiem an t 20 - 30 nam.
Benh ly U 84
Cau truc bo gen cua HTLV-1 cung co

cha cac gen gag, pol, env va LTR nh cac
retrovirus khac, ngoai ra con co them 1 gen
tax au 3. C che gay ung th cua HTLV-1
khong giong vi 2 loai virut ARN sinh u a noi
tren; bi v no khong cha cac v-onc va cung
khong c to hp ngau nhien vao canh mot
tien-oncogen nao cua te bao chu. Kha nang
gay ung th cua HTLV-1 la do hoat ong cua
gen tax: protein tax co kha nang hoat hoa mot
so gen cua te bao chu, th du nh gen ma hoa
cho IL-2 va thu the tng ng, gen ma hoa cho
GM-CSF. Khi vao c c the, virut HTLV-1
xam nhap va kch thch s tang sinh nhieu
dong te bao T theo kieu t tiet (qua s san
xuat IL-2 va thu the tng ng) hoac can tiet
(qua s san xuat GM-CSF kch thch ai thc
bao san xuat IL-1). S tang sinh a dong te
bao T tao thuan li cho viec xay ra cac ot
bien mi, lam xuat hien 1 dong te bao T tang Hnh 40: C che gay ung th cua HTLV-1
sinh troi hn, dan en ung th. (Hnh 40)
2. Virut ADN sinh u:

en nay, ch co 3 loai virut ADN c xac nh la co kha nang gay ung th ngi. Khi
xam nhap vao te bao, ADN cua virut thng c to hp ben vng vi ADN cua te bao chu;
nh o ta co the phat hien ra s hien dien cua chung bang ky thuat lai ghep phan t.
a. Cac papillomavirus ngi (HPV):

Phan tch di truyen cho thay co
khoang hn 100 typ HPV khac nhau. HPV
typ 1, 2, 4, 7 co kha nang gay u nhu da
lanh tnh; cac HPV typ 6, 11, 42, 44, 53,
54, 62, 66 ( goi chung la HPV typ nguy c
thap) gay ra mot loai u lanh co t cung
goi la condylom; trai lai, HPV typ 16, 18,
31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68
(goi chung la HPV typ nguy c cao) co the
gay ra ung th co t cung; ngi ta a tm
thay ADN cua HPV typ nguy c cao trong
75 - 95% trng hp ung th co t cung.
(Hnh 41)
Hnh 41: C che sinh u cua HPV
S khac biet ve kha nang sinh u gia cac HPV typ nguy c thap va HPV typ nguy c
cao la do phng cach hoat ong cua virut trong te bao chu: ADN cua typ nguy c thap ton tai
di dang ADN vong (episome) va khong c to hp vao ADN te bao chu; trai lai, ADN cua
typ nguy c cao c to hp ngau nhien vao ADN te bao chu, dan en s tang bieu hien 2 gen
E6 va E7 cua virut. Protein E7 gay bat hoat protein p53 va Rb cua te bao chu, protein E6 thuc
ay s giang hoa p53 va protein bax ong thi tai hoat hoa telomerase; ket qua la te bao chu b
thuc ay tang sinh va bat t hoa.
Benh ly U 85
Tuy nhien s nhiem HPV n thuan cha u e gay ra ung th ma phai can them mot
so ot bien gen khac (chang han nh ot bien tien-oncogen ras), nay a de xay ra hn do bo
gen te bao chu khong con on nh nh luc cha b nhiem virut.
b. Virut Epstein-Barr (EBV):
La virut thuoc ho Herpes, c xem la nguyen nhan gay ra 2 loai ung th la limphom
Burkitt va carcinom khong biet hoa cua vom hau.
Limphom Burkitt hay gap 1 so vung cua Chau Phi, ngi ta a tm thay ADN cua EBV
trong te bao ung th cua tat ca cac benh nhan nay. EBV co ai tnh manh vi cac limpho bao B,
sau khi xam nhap se kch thch limpho bao B tang sinh. Trong c the bnh thng, s tang sinh
limpho bao B c kiem soat nhng nhng benh nhan b suy giam mien dch (do mac benh
sot ret hoac nhiem trung), c che kiem soat khong con hieu qua; cac limpho bao B tiep tuc tang
sinh, tao thuan li cho s xay ra cac ot bien mi, lam xuat hien 1 dong limpho bao B tang sinh
troi hn, dan en limphom Burkitt.
Carcinom khong biet hoa cua vom hau la ung th thng gap vung ong nam A va
Trung quoc, ngi ta a tm thay ADN cua EBV trong te bao ung th cua tat ca cac benh nhan
mac loai ung th nay. Tng t nh trong limphom Burkitt, EBV co the a tng tac vi 1 so yeu
to khac e gay ra carcinom khong biet hoa cua vom hau.
c. Virut viem gan B (HBV):
Cac nghien cu dch te hoc cho thay co moi lien he chat che gia tnh trang nhiem HBV
man tnh vi ung th gan. C che gay ung th cua HBV van cha c biet ro mac du co s to
hp gia ADN cua virut va ADN te bao chu. C che sinh u cua HBV co le thong qua kha nang
gay ton thng lam chet te bao gan khien cac te bao gan con lai phai tang sinh lien tuc, tao
thuan li cho s xuat hien cac ot bien mi dan en ung th.
Ngoai cac virut tren. gan ay a xac nh c vai tro cua vi khuan Helicobacter pylori
(Hp) trong 2 loai ung th da day la carcinom tuyen va limphom te bao B. C che gay ung th
cua Hp co le thong qua kha nang gay viem da day man tnh; dan en chuyen san ruot , nghch
san va cuoi cung la carcinom tuyen. S tang sinh a dong te bao limpho B trong viem da day
man tnh tao thuan li cho viec xay ra cac ot bien mi, lam xuat hien 1 dong te bao B tang sinh
troi hn, dan en limphom da day.
Tom lai, nghien cu ve cac virut sinh u a giup chung ta phat hien ra s ton tai cua cac
tien-oncogen ngi, ma en nay a biet hn 100 loai khac nhau. Mac du a so cac loai ung
th ngi khong phai do virut trc tiep gay ra, nhng chnh s hoat hoa cac tien-oncogen
cung vi s bat hoat nhieu loai gen khac na, a gay ra chuyen dang te bao soma, dan en s
hnh thanh cac khoi u nh c thay trong phan tiep sau ay.
VII. C s phan t cua qua trnh sinh ung (carcinogenesis):
Mau chot cua qua trnh sinh ung la cac ot bien gen khong gay chet xay ra tren 4 loai
gen sau:
- Tien-oncogen (proto-oncogene)
- Gen c che u (tumor suppressor gene)
- Gen ieu hoa s t huy te bao (apoptosis)
- Gen sa cha ADN
Cac ot bien gen khong gay chet nay xay ra la do tac ong cua cac yeu to moi trng
(virut, hoa hoc, bc xa), do bo me truyen cho (th du gen gay u nguyen bao vong mac) hoac co
tnh t phat.
A. Tien-oncogen:
Trong ieu kien sinh ly bnh thng, s tang sinh te bao c kiem soat rat chat che,
mot te bao muon hoat ong tang sinh th phai qua cac bc sau (Hnh 42):
Benh ly U 86
- Co yeu to tang trng ac hieu.
- Gan ket yeu to tang trng len thu
the tng ng co tren be mat te bao; s
gan ket nay phat ra tn hieu tang sinh cho
te bao.
- Tn hieu c chuyen t mang te
bao vao trong nhan nh vao hoat ong
cua cac protein truyen tn hieu co tren
mang te bao va trong bao tng.
- Gen ma hoa cho protein ieu hoa
sao chep c hoat hoa, protein ieu hoa
sao chep c tong hp, i vao trong
nhan kch thch s tong hp ADN lam te
bao phan chia.
Cac tien-oncogen gi vai tro quan
trong oi vi s tang sinh te bao; bi v
chung ma hoa cac protein can thiet cho tat Hnh 42: Cac bc kiem soat s tang sinh te bao: Yeu to
ca cac bc tren nh cac yeu to tang tang trng (1), thu the tng ng (2), protein truyen tn
trng, protein truyen tn hieu, protein ieu hieu mat trong mang te bao (3) va t do trong bao
hoa sao chep trong nhan. tng (4), protein ieu hoa sao chep (5)
Chnh v vay, khi cau truc cua tien-oncogen b thay oi do cac ot bien hoac khi s bieu
hien cua no b roi loan, tien-oncogen c hoat hoa thanh oncogen-te bao (c-onc), co kha nang
kch thch te bao chuyen dang tang sinh mot cach qua mc va t ong, thoat khoi moi c che
kiem soat bnh thng trong c the.
Bang sau ay gii thieu 1 so trong hn 100 tien-oncogen a c biet cho en nay va
cac loai u co the xuat hien khi cac tien-oncogen nay c hoat hoa thanh oncogen- te bao:
Tien-oncogen NST Protein c ma hoa Loai U

sis 22q YT tang trng PDGF U than kinh em, sarcom
int2 11q YT tang trng FGF Carcinom vu
erb B-1 7q Thu the EGF Carcinom TB gai
erb B-2 17q Thu the EGF typ 2 Carcinom tuyen vu
kit 4q Thu the SCF Sarcom mo em ng tieu hoa
ret 10q Thu the GDNF Carcinom tuyen giap, hoi chng tan sinh a
tuyen noi tiet typ 2
fes 15q Tyrosine kinase bao tng Sarcom
h-ras 11p GTPase mang Ung th tuyen tuy, ai trang, phoi
k-ras 12p GTPase mang Ung th tuyen giap
n-ras 1p GTPase mang Carcinom, melanoma
src 20p Tyrosine kinase bam mang Ung th ai trang, phoi, vu
myc 8q Protein ieu hoa sao chep Carcinom
n-myc 2p Protein ieu hoa sao chep U nguyen bao Than kinh
l-myc 1p Protein ieu hoa sao chep Carcinom phoi
fos 14q Protein ieu hoa sao chep Sarcom xng
Chu thch: PDGF, yeu to tang trng xuat phat t tieu cau (platelet derived growth factor); FGF, yeu to tang trng nguyen
bao si (fibroblast growth factor); EGF, yeu to tang trng bieu b (epidermal growth factor); SCF, yeu to te bao goc (Stem
cell factor); GDNF, yeu to hng than kinh xuat phat t dong te bao than kinh em ( Glial cell line derived neutrotrophic
factor)
Cac oncogen c xem la nhng gen ung th troi (dominant cancer gene) bi v ch can
mot trong 2 tien-oncogen alen vi nhau b hoat hoa thanh oncogen la u e co tac ong sinh u.
Th du (hnh 43):
- Khi 1 trong 2 tien-oncogen sis (simian sarcoma) b hoat hoa thanh oncogen c-sis, san
pham bnh thng cua no la yeu to tang trng PDGF se c san xuat qua mc, co kha nang
kch thch te bao tang sinh tao thanh u; th du nh u sao bao, sarcom xng.
Benh ly U 87
- Tien-oncogen erb B-1 ( avian erythroblastosis) ma hoa cho protein thu the oi vi yeu
to tang trng bieu b EGF (epidermal growth factor), khi b hoat hoa thanh oncogen c-erb-1 se
khien protein thu the nay c san xuat qua mc, ket qua te bao tang sinh manh du ch co t
yeu to tang trng tac ong. Ghi nhan co s hoat ong cua oncogen nay trong 80% cac trng
hp carcinom te bao gai phoi. Tng t nh vay, khoang 30% cac trng hp carcinom tuyen
vu di can, co s hoat hoa tien oncogen erb B-2 thanh oncogen c-erb-2 (con goi la oncogen Her-
2/neu).
- Tien-oncogen ras (rat sarcoma) ma hoa cho 1 protein truyen tn hieu tang sinh nam
mat trong mang te bao. Cac ot bien iem xay ra tren tien-oncogen ras se bien no thanh
oncogen c-ras co kha nang kch thch te bao tang sinh tao thanh u, du khong co yeu to tang
trng tac ong. Ghi nhan co s hoat ong cua oncogen nay trong khoang 30% cac ung th
ngi.
- Tien-oncogen myc (myelocytomatosis), ma hoa cho 1 protein ieu hoa sao chep trong
nhan. Cac chuyen oan nhiem sac the, khuyech ai gen co the bien tien-oncogen myc thanh
oncogen c-myc; ket qua protein ieu hoa tren c san xuat qua mc, kch thch te bao tang
sinh tao thanh cac ung th nh limphom Burkitt, ung th phoi loai te bao nho.
Hnh 43: S o hoat hoa cac tien oncogen thanh oncogen te bao, tac ong sinh u.
B. Gen c che u (tumor suppressor gene):

Cac gen c che u gi vai tro km ham s tang sinh te bao; chung ma hoa cho cac yeu to
c che tang trng, cac phan t ieu hoa s ket dnh gia cac te bao, phan t truyen tn hieu c
che va cac phan t ieu hoa sao chep trong nhan. Cac ot bien gay thieu hut hoac bat hoat cac
gen nay co the dan en s hnh thanh u do s tang sinh te bao khong con b km ham na. V
Benh ly U 88
ca 2 gen c che u alen vi nhau phai cung b thieu hut hoac bat hoat th mi co tac ong sinh
u nen chung con c goi la cac gen ung th lan (recessive cancer gene).
Bang sau ay gii thieu 1 so trong hn 30 gen c che u a c biet cho en nay:
Gen NST Protein c ma hoa Loai U
c che u
CDH1 16q E-cadherin tren mang te bao, giup Ung th da day

gan ket cac te bao
DCC 18q Thu the netrin 1 tren mang te bao Ung th ai-trc trang, U te bao mam sinh
duc nam
APC 5q Protein bao tng c che s truyen Ung th ai-trc trang

tn hieu
RB 13q Protein ieu hoa sao chep U nguyen bao vong mac; ung th phoi, tuyen
tien liet, sarcoma xng,
p53 17p Protein ieu hoa sao chep Hau het cac loai ung th
WT1 11p Protein ieu hoa sao chep U nguyen bao than, u phan mem
1. Gen Rb: la gen c che u au tien c phat hien, nam tren nhiem sac the 13. Khi ca
2 gen Rb b bat hoat se dan en s hnh thanh u nguyen bao vong mac, mot loai ung th tre em
hiem gap. Trong nhieu loai ung th cua ngi ln nh ung th phoi, ung th vu va ung th ruot
gia, cung thay co s bat hoat ca 2 gen Rb.
Gen Rb ma hoa cho protein

Rb (pRb). Bnh thng khi te bao
ngh ngi giai oan G0 hoac G1,
pRb dang khong b phosphoryl
hoa, co kha nang c che cac protein
ieu hoa sao chep lam cho s tang
sinh cua te bao b km ham. Trai lai,
khi te bao nhan c tn hieu tang
sinh, pRb c phosphoryl hoa se
khong con c che cac protein ieu
hoa sao chep, cac te bao i vao
phan chia. Nh vay, khi ca 2 gen Rb
b thieu hut hoac khi pRb b bat hoat,
protein ieu hoa sao chep khong b
c che se khien te bao tang sinh t
do, dan en s hnh thanh u (Hnh Hnh 44: C che tac ong cua gen Rb
44).
ay can giai thch v sao u nguyen bao vong mac-the di truyen c xem la 1 ung th
di truyen troi nhiem sac the thng trong khi o gen Rb lai la gen ung th lan: Trong the benh di
truyen nay, tre sinh ra a nhan c 1 gen Rb b bat hoat t bo hoac me, gen alen Rb con lai
van bnh thng nen tat ca cac te bao soma trong c the tre eu tnh trang d hp t ve gen
Rb lanh. Cac te bao vong mac cua tre ban au van bnh thng v ch can co 1 gen Rb lanh
cung u am bao chc nang km ham s tang sinh te bao. Tuy nhien, tnh trang d hp t ve
gen Rb lanh cua te bao vong mac de b mat i do 1 ot bien mi lam bat hoat gen Rb lanh con
lai (Loss of heterozygosity), khien s tang sinh cua te bao nay khong con kiem soat c, dan
en u nguyen bao vong mac. Trai lai, trong u nguyen bao vong mac - the le te, tre sinh ra nhan
u 2 gen Rb lanh t bo me; v the e tao c u th phai co 1 te bao vong mac chu 2 lan ot
bien lien tiep e bat hoat ca 2 gen alen Rb (mo hnh 2 cu anh cua Knudson); ieu nay t kha
nang xay ra hn so vi ch 1 lan ot bien trong the di truyen. Nh vay, gen Rb la 1 gen ung th
lan, nhng trong u nguyen bao vong mac-the di truyen th tnh trang d hp t lam de b u
nguyen bao vong mac a c truyen theo kieu troi - nhiem sac the thng. (Hnh 45)
Benh ly U 89
Hnh 45 : Mo hnh 2 cu anh cua Knudson trong c che phat sinh u nguyen bao vong mac
2. Gen p53: la mot gen c che u khac nam tren nhiem sac the 17. Ngi ta ghi nhan co
s bat hoat ca 2 gen alen p53 trong hau het cac loai ung th ngi.
Hnh 46: C che tac ong cua gen p53
Khac vi gen Rb, hoat ong km ham cua gen p53 ch xay ra khi ADN cua te bao b ton
thng (mot cach t phat hoac do tac ong cua cac yeu to moi trng). Khi o, ham lng
protein p53 trong nhan tang len nhanh chong, giup te bao ngng lai giai oan G1 e co thi
gian sa cha cac ton thng tren ADN. Neu sa cha thanh cong, te bao tiep tuc i vao giai
oan S va hoat ong tang sinh bnh thng; trng hp that bai, protein p53 se lam tang san
xuat protein Bax va Bak, ong thi c che bcl-2; ket qua la te bao b thuc ay i vao qua trnh t
Benh ly U 90
huy. Nh vay, khi ca 2 gen p53 eu b ot bien bat hoat (do nhiem HPV, EBV, HBV), cac te
bao du ang b ton thng ADN van tiep tuc tang sinh va co the dan en ung th (Hnh 46)
C. Gen sa cha ADN:

Cac ton thng ADN van thng xuyen xay ra trong qua trnh hoat ong cua te bao, mot
cach t phat hoac do tac ong cua cac yeu to moi trng. Tuy nhien phan ln cac ton thng
nay eu c sa cha kp thi nh vao hoat ong cua cac gen sa cha ADN san co nh gen
MSH2, MLH1, PMS1, PMS2 v.v... Do o khi cac gen nay b thieu hut hay bat hoat th se lam
tang nguy c xuat hien ung th (Hnh 47).
Th du: Trong benh kho b sac to, co s khiem khuyet ve cac gen sa cha ADN v vay
cac ton thng ADN do bc xa cc tm gay ra khong c sa cha kp thi, benh nhan de b
ung th da hn ngi bnh thng.
D. Cac gen ieu hoa s t huy te bao (apoptosis):

Gom 2 nhom gen co tac ong trai ngc nhau:
- Gen thuc ay s t huy te bao, th du nh cac gen bad, bax, bak, bim, bid, bik, bok,...
- Gen c che s t huy te bao, th du gen Bcl-2, Bcl-XL, Bcl-X,...
Cac ot bien gay thieu hut nhom gen th nhat hoac lam tang bieu hien cua nhom gen
th hai se khien cac te bao du co ton thng ADN van khong t huy, tiep tuc song sot va tang
sinh, dan en s hnh thanh ung th (Hnh 47).
Hnh 47: Hoat ong cua cac gen sa cha ADN va cac gen ieu hoa s t huy te bao
Tom lai, qua trnh phat trien t nhien cua ung th gom 4 bc noi tiep nhau la chuyen
dang ac tnh, tang trng u, xam nhap va di can. Xet ve mat phan t, dien tien tuan t tng
bc nay tng ng vi s tch luy cac ot bien (xuat hien t phat hoac do tac ong cua moi
trng) lam hoat hoa cac tien-oncogen, bat hoat cac gen c che u, gen ieu hoa s t huy te
Benh ly U 91
bao va gen sa cha ADN. Trong s hnh thanh moi loai ung th ngi, c lng phai co
t 3 en 7 ot bien nh vay.
Th du trong carcinom tuyen ai trang; ngi ta cho rang ton thng bat au bang s
chuyen dang va tang sinh te bao bieu mo tuyen tao thanh 1 u tuyen lanh tnh; u tuyen nay ln
dan va sau cung hoa ac, xam nhap tai cho qua cac lp thanh ruot va cho di can. Dien tien nay
tng ng vi s bat hoat trc tien cac gen c che u APC va gen sa cha ADN MSH2, tiep
theo la s hoat hoa tien-oncogen ras, roi en cac ot bien lam thieu hut cac gen c che u khac
nh DCC, p53 va them nhieu gen khac na (Hnh 48).
Hnh 48: S tch luy ot bien trong qua trnh hnh thanh carcinom tuyen ai trang.
VIII. Lien he lam sang:

A. Tac ong cua u tren c the:
Moi khoi u eu la nhng vat ky sinh tren c the, co the gay ra nhng tac ong t nhe
en nang, tuy vao v tr xuat hien va tnh chat lanh hoac ac cua chung.
1. Tai cho:
S phat trien cua khoi u se chen ep va can tr hoat ong cua cac mo - c quan lan can,
v vay co the gay nguy hiem neu u xuat hien nhng v tr quan trong, cho du o la 1 u lanh
tnh.
Th du:
- Mot u tuyen yen lanh tnh co kch thc nho, ng knh 1 cm, van co the chen ep
pha huy mo tuyen bnh thng xung quanh, dan en tnh trang suy tuyen yen. Cac u nao, du
lanh hoac ac eu nguy hiem tnh mang do kha nang lam tang ap lc noi so, chen ep len cac
cau truc quan trong cua he than kinh trung ng.
- U thanh ruot, du lanh tnh, van co the dan en long ruot va tac ruot.
- Cac u lanh co tnh di ong, nh u nang buong trng, polyp ai trang; co the b xoan lai
gay xuat huyet, hoai t.
Benh ly U 92
2. Toan than:
a/ Tac ong noi tiet: xay ra oi vi nhng u xuat phat t tuyen noi tiet, th du:
- U vo thng than, lanh hoac ac, co the gay ra hoi chng Cushing do te bao u san xuat
qua nhieu corticosteroid.
- U te bao beta tuyen tuy co the gay ha ng huyet do san xuat qua nhieu insulin.
b/ Suy mon: la tnh trang bien mat dan khoi c - m trong c the, hay gap cac benh
nhan ung th. Tnh trang suy mon uc giai thch la do s thay oi ve v giac, mat cam giac
them an hoac do tac ong cua mot so cytokin lu hanh trong mau.
c/ Hoi chng can ung th (Paraneoplastic syndrome):

La cac phc hp trieu chng xay ra cac benh nhan ung th ( khoang 10% so benh
nhan ung th) ma khong the giai thch c bang s xam nhap tai cho hoac di can xa cua khoi
u, hoac bang hoat ong san xuat cac hormon von co mo nguyen uy cua khoi u.
Cac hoi chng can ung th thng gap la hoi chng Cushing, s tang canxi mau, huyet
khoi tnh mach. Cac loai ung th thng co hoi chng can ung th la ung th phoi, ung th vu va
ung th he tao huyet. Th du:
- Trong ung th phoi loai te bao nho, co the gap hoi chng Cushing va tang canxi mau
do te bao u co kha nang san xuat ra ACTH va cac peptid tng t hormon tuyen can giap.
- Ha ng huyet co the gap benh nhan b sarcom si, u mo em ng tieu hoa; do
te bao u san xuat c insulin hoac chat tng t insulin.
- Huyet tac tnh mach co the gap ung th phoi, ung th tuyen tuy, do te bao u san xuat
cac chat hoat hoa he thong ong mau.
B. Xep giai oan ung th (Staging of cancer):
Nham anh gia mc o lan tran cua ung th, lam c s cho viec xac nh phac o ieu
tr hp ly, anh gia tien lng, so sanh hieu qua cua cac phng phap ieu tr khac nhau hoac
gia cac c s ieu tr. e xep giai oan, ngi ta da vao kch thc cua khoi u nguyen phat,
mc o xam nhap vao mo xung quanh, mc o di can vao cac hach bach huyet va di can xa.
Giai oan ac iem
0 Ung th tai cho
I Xam nhap tai cho con sm, khong co di can
II Bat au lan rong va di can en hach vung
III Lan rong va di can en nhieu hach
IV Co di can xa
Th du : Ung th co t cung c xep thanh 5 giai oan nh sau:

Neu ung th co t cung c phat hien sm giai oan 0 th kha nang cha khoi bang
phng phap ieu tr tai cho n gian nh khoet chop la 100%; trai lai khi a vao giai oan IV
th coi nh khong con kha nang cha khoi, du vi bat ky phng phap ieu tr nao.
e viec xep giai oan ung th mang tnh khach quan, Hiep hoi quoc te chong ung th
(UICC) a a ra he thong xep hang TNM ( Tumor, Nodes, Metastasis) ma t nhieu nam nay a
c ap dung rong rai tai cac c s ieu tr. Sau ay la cac nh ngha c dung trong he
thong nay:
Benh ly U 93
T Khoi u nguyen phat (Tumor)
Tx U nguyen phat khong the anh gia c
T0 Khong tm thay u nguyen phat
Tis Carcinom tai cho
T1,2,3,4 Kch thc u va/ hoac mc o lan rong tai cho tang dan
N Hach bach huyet vung (Nodes)

Nx Hach vung khong anh gia c
N0 Khong thay di can hach vung
N1,2,3 So hach b di can tang dan
M Di can xa (Metastasis)
Mx Di can xa khong anh gia c
M0 Khong thay di can xa
M1 Co di can xa
C. Cac chat anh dau u (tumor marker):

La cac san pham cua te bao u c phong thch vao trong tuan hoan. nh lng huyet
thanh cac chat nay co the tr giup cong tac chan oan va theo doi ieu tr mot so benh ung th.
Th du:
- Alpha fetoprotein (AFP) la 1 protein phoi c tm thay trong gan, tui noan hoang va
ong tieu hoa cua phoi thai. AFP tang cao trong cac ung th gan, ung th te bao mam cua tinh
hoan va buong trng
- Khang nguyen carcinom phoi CEA (carcinoembryonic antigen) la 1 glycoprotein do
gan, tuyen tuy va ong tieu hoa cua phoi thai san xuat. CEA co the tang cao trong ung th vu,
buong trng, ai trang, ung th phoi loai te bao nho.
- HCG (human chorionic gonadotropin) la 1 glycoprotein do hp bao nuoi san xuat, tang
cao trong cac u te bao nuoi
- Calcitonin la 1 hormon c san xuat bi te bao C cua tuyen giap, tang cao trong cac
ung th tuyen giap dang tuy
- Khang nguyen ac hieu tuyen tien liet PSA ( Prostate specific antigen) la 1 protease
do bieu mo tuyen tien liet san xuat, tang cao trong ung th tuyen tien liet.
- Phosphatase acid tuyen tien liet - PAP (prostatic acid phosphatase) tang cao
nhng benh nhan b ung th di can tuyen tien liet.
- Lactate dehydrogenase (LDH) tang cao nhng benh nhan benh bach cau, u hac to,
cac limphom.
- Enolase ac hieu nron NSE ( Neuron specific enolase) la 1 glycoprotein co nguon
goc than kinh, tang cao trong cac u than kinh noi tiet, u nguyen bao than kinh.
- Khang nguyen ung th CA (cancer antigen) la cac glycoprotein khong thay te bao
bnh thng nen rat co gia tr trong tam soat ung th. Co nhieu loai CA khac nhau: CA 15-3,
tang cao trong ung th vu; CA 19-9, tang cao trong ung th tuyen tuy; CA 72-4, tang cao trong
ung th vu va buong trng; CA-125, tang cao trong ung th buong trng.
D. Tam soat ung th:
Kha nang cha khoi mot ung th tuy thuoc rat ln vao viec phat hien sm khi no con
trong thi ky tien lam sang. S hieu biet ro hn ve ban chat cua moi loai ung th cung vi ket
qua ieu tra dch te hoc cho phep xac nh cac nhom nguy c cao e t o tm ra nhng bien
phap tam soat thch hp. Sau ay la che o tam soat mot so loai ung th thng gap do Hiep
hoi ung th Hoa ky ACS (American Cancer Society) e ngh:
Benh ly U 94
Muc tieu tam soat Ky thuat tam soat Ch nh Thi bieu
UT. ruot gia Noi soi ai trang sigma 50 tuoi moi 3-5 nam
Tm mau an trong phan 50 tuoi moi nam
Tham kham trc trang an ong 40 tuoi moi nam
UT. tuyen tien liet nh lng PSA an ong 50 tuoi moi nam
UT.sinh duc n Tham kham vung chau va lam Phu n 18 - 40 tuoi moi 3 nam
Phet mong Papanicolaou
Phu n > 40tuoi moi nam
UT. vu T kham vu Phu n 20 tuoi moi thang
i kham vu Phu n 20 - 40 tuoi moi 3 nam
Phu n > 40 tuoi moi nam
Chup nhu anh

Phu n 40 - 49 tuoi moi 1 - 2 nam
Phu n 50 tuoi moi nam
UT. da Kham da 20 - 39 tuoi moi 3 nam
1. Lipoma la ten goi cua u lanh xuat phat t:

A/ Te bao c van B/ Te bao c trn C/ Te bao m
D/ Te bao limpho E/ Te bao sun
2. ac iem vi the cua u lanh la:
A/ Te bao rat a dang B/ Te bao tang san nhng khong d dang
C/ Nhan to nho khong eu D/ Bao tng co nhieu the vui E/ Te bao d dang
3. Nghien cu ve cac retrovirus sinh u a giup phat hien ra bo gen ngi bnh thng co cha:
A/ Gen sa cha ADN B/ Tien oncogen C/ Gen thuc ay s t huy te bao
D/ Gen c che s t huy te bao E/ Gen c che u
4. Trc 1 phu n 35 tuoi c tam soat ung th co t cung bang phet mong Pap, phat hien co
cac te bao gai nghch san nang (HSIL), can a ra khuyen cao:
A/ Ton thng nay co the tien trien thanh carcinom te bao gai xam nhap co t cung
B/ Phu n nay co the ang co mot u quai trng thanh buong trng
C/ Ton thng nay la mot carcinom te bao gai xam nhap co t cung ang thoai trien
D/ Can s dung ngay vaccin nga HPV
E/ Cac thanh vien n khac trong gia nh cua phu n nay co nguy c b ton thng tng t
5. iem khac biet quan trong nhat e phan biet gia u thc va u gia la:
A/ Kch thc u B/ Hnh dang u C/ Tnh sinh san t ong cua te bao u
D/ Mat o u E/ Mat cat u
6. Dang ai the cua u ac xuat phat t bieu mo phu t khi co dang:
A/ Khoi san sui B/ Loet C/ Phoi hp sui-loet
D/ Nhieu cuc nho E/ Tham nhiem
Benh ly U 95
7. Mot benh nhan nam c phat hien tnh c co khoi u phoi qua chup x-quang; khao sat vi the
cho thay u tao bi cac mo sun, c trn va bieu mo ho hap trng thanh nhng sap xep lon xon,
nhieu kha nang ay la:
A/ Carcinom phe quan B/ Choristom phoi C/ Hamartom phoi
D/ U quai di can phoi E/ Ton thng lao phoi cu
8. Cau tao vi the cua moi loai u eu co 2 thanh phan la:

A/ Bieu mo va trung mo B/ Mo chu u va mo em u
C/ Mo ung th va mo lanh quanh u D/ Mo chu u va mach mau tan sinh
E/ Mo chu u va mach bach huyet
9. Grad mo hoc cua 1 u ac c xac nh da vao:
A/ o biet hoa cua te bao u B/ Ch so phan bao trong khoi u
C/ Cau tao mo hoc cua u D/ Ch A, B ung E/ Ca A, B, C ung
10. Khi noi te bao u khong con b tac ong bi gii han Hayflick, co ngha la :
A/ Te bao u a tr nen bat t B/ Te bao u co the phan bao bat thng
B/ Te bao u san xuat c enzym telomerase c che s thoai hoa au mut nhiem sac the
D/ Tat ca A, B, C ung E/ Ch A va C ung
11. Neu khong co s tang sinh mach mau trong khoi u th ng knh khoi u khong the vt qua:
A/ 0, 2 mm B/ 1- 2 mm C/ 1cm D/ Tren 2 cm E/ 20 cm
12. Thi gian nhan oi (TGN):
A/ La thi gian can thiet e ng knh khoi u tang gap oi
B/ Bieu th toc o tang trng khoi u
C/ TGN cang ngan th thi ky tien lam sang cang dai ra
D/ TGN giong nhau cho moi loai ung th
E/ Tat ca A, B, C, D sai
13. Cac o ung th th phat do di can theo ng mau thng thay nhat :
A/ Gan B/ Phoi C/ C tim
14. oi vi cac Carcinom, co the d oan vung hach b di can da vao:

A/ V tr khoi u nguyen phat B/ He thong mach bach huyet cua vung cha u
C/ He thong tnh mach cua vung cha u D/ Ch A va B ung E/ Ch A va C ung
15. Phau thuat mo bung tham sat 1 benh nhan n b ung th buong trng cho thay o bung
cha ay dch va co nhieu not di can tren tren mac noi va mac treo ruot; tnh trang nay la do te
bao u a di can theo:
A/ ng mau B/ ng mach bach huyet C/ ng ong t nhien
D/ ng than kinh E/ ng nhan tao
16. S gia tang ham lng AFP trong mau 80% benh nhan b carcinom te bao gan la do:
A/ Te bao gan b hoai t B/ Gen ma hoa cho AFP b ot bien
C/ Gen ma hoa cho AFP von b ong do s biet hoa te bao gan, nay c giai c che
D/ Te bao gan san xuat telomerase E/ Te bao gan b mat
17. Sarcom KHONG CO ac iem:

A/ La u ac B/ Xuat nguon t mo lien ket
C/ Kho phan biet gia mo chu va mo em D/ Co the hien dien moi vung c the
E/ Tien lng thng tot
18. Phan so tang trng cua mot khoi U:

A/ La t le te bao ang hoat ong tang sinh trong khoi u
B/ Thung khong qua 20% vao thi iem U c phat hien tren lam sang
C/ T le thuan vi toc o tang trng cua khoi U
D/ Ca A, B, C ung E/ Ch A, C ung
Benh ly U 96
19. Cac tien-oncogen:
A/ Ch hien dien trong nhan cua te bao ung th
B/ Khi b ot bien, co the kch thch te bao chuyen dang thanh bao u
C/ Con goi la gen ung th troi
D/ Ca A, B, C ung
E/ Ch B va C ung
20. Gen p53:

A/ La 1 gen c che u, ma hoa cho protein p53
B/ Protein p53 giup te bao co ton thng ADN ngng tang sinh e sa cha
C/ Khi 1 trong 2 gen alen p53 b bat hoat th te bao du co ton thng ADN van tiep tuc
tang sinh, lam xuat hien ung th
Ton thng Huyet quan-Huyet 97
TON THNG HUYET QUAN - HUYET
Muc tieu:
1. nh ngha phu. Phan tch c che benh sinh cua cac loai phu khong do viem.
2. nh ngha sung huyet. Phan tch c che benh sinh cua sung huyet ong va
sung huyet tnh
3. nh ngha va mo ta cac hnh thai cua xuat huyet.
4. nh ngha huyet khoi. C che benh sinh, tien trien va hau qua cua huyet khoi
5. nh ngha huyet tac. Neu ban chat cua cuc huyet tac, phan loai va hau qua
cua huyet tac.
6. nh ngha nhoi mau. Mo ta, phan tch hai loai nhoi mau o va nhoi mau trang va
hau qua cua nhoi mau
7. nh ngha va c che benh sinh cua soc.
Roi loan tuan hoan va roi loan can bang dch co the gay ra nhng ton thng nh: phu,
sung huyet, xuat huyet, soc va 3 ton thng co lien he mat thiet vi nhau la huyet khoi, huyet
tac va nhoi mau. Cac ton thng nay rat thng gap va la nguyen nhan chnh gay ra cac t
vong, th du nh soc tim, nhoi mau c tim, xuat huyet nao, huyet tac phoi...
I. PHU (edema):
1. nh ngha
La s ong 1 lng dch bat thng trong mo ke gian bao hoac trong khoang c the.
Phan biet 2 loai phu :
- Phu viem: do tang tnh tham thanh mach. Dch ong ay goi la dch xuat (exudate)
hay con goi la dch phu viem, co ham lng protein cao 3g%, t trong > 1,020.
- Phu khong do viem: do cac thay oi huyet ong hoc, lam gia tang lc ay dch t trong
long mach vao khoang ke. Dch ong goi la dch tham (transudate), co ham lng protein thap
< 3g%, t trong < 1,012. ay la loai phu se c e cap di ay
Ca hai loai phu eu co the dang lan toa hay khu tru. S ong dch khu tru trong cac
khoang mang phoi, bao tim va mang bung c goi la tran dch mang phoi, tran dch mang tim
va tran dch mang bung (con goi la co trng).
2. C che benh sinh
Theo nh luat Starling, s trao oi dch gia khoang ke va khoang trong long mach chu
s tac ong cua ap lc thuy tnh va ap lc tham thau cua ca hai khoang nay, trong o ap lc
thuy tnh (ALTT) trong long mach va ap lc tham thau keo (ALTTK) cua huyet tng gi vai tro
chnh.
au tieu ong mach cua he
mao mach, ALTT la 35 mmHg, giam dan
en 12 - 15 mmHg tai au tieu tnh
mach. Trai lai, ALTTK tai au tieu ong
mach la 20-25mmHg va ch tang len
chut t tai au tieu tnh mach do s thoat
dch. Ket qua, dch se c ay t long
mach vao mo ke phan mao mach pha
au ong mach sau o phan ln se
c hut tr lai pha au tnh mach,
mot phan nho se c dan lu vao cac
mach bach huyet. (Hnh 1)
Hnh 1: C che trao oi dch gia khoang mach va mo ke
Nh vay, phu khong do viem co the xay ra do cac nguyen nhan sau:
- Tang ALTT trong long mach.
- Giam ALTTK cua huyet tng.
- Giam dan lu vao mach bach huyet.
a/ Tang ALTT (hydrostatic pressure): co the tang cuc bo hoac toan bo.
- Ap lc thuy tnh tang cuc bo: tnh mach chi di b tac do huyet khoi lam tang ap lc
thuy tnh, gay ra phu chi di. X gan lam tang ap lc thuy tnh trong tnh mach ca, gay ra tran
dch mang bung, con goi la co trng. (Hnh 2A)
- Ap lc thuy tnh tang toan bo: suy tim huyet lam tang ap lc thuy tnh trong toan bo he
tnh mach, gay ra phu phoi va toan than.
b/ Giam ap lc tham thau keo cua huyet tng (colloid osmotic pressure):
Ap lc tham thau keo cua huyet tng giam khi nong o protein trong huyet tng giam,
gay ra phu toan than. Protein huyet tng giam co the do:
- Tang that thoat: hoi chng than h.
- Giam tong hp: x gan, suy dinh dng nang the Kwashiokor.
c/ Tac mach bach huyet: lam can tr s dan lu dch ke vao trong mach bach huyet, ket
qua gay ra phu. Th du:
- Phu chan voi trong benh nhiem giun ch (filiriasis), do giun ch gay tac nghen mach bach
huyet vung ben. (Hnh 2B)
- Phu canh tay do cac hach nach b nao bo trong phau thuat cat ieu tr ung th vu.
Hnh 2: Tran dch mang bung va tran dch tinh mac (A); Phu chan voi ben phai (B)
3. Hnh thai ton thng

a/ ai the:
Moi mo va c quan eu co the b phu nhng thng gap nhat 3 ni: mo di da (thng
chi di), phoi, nao. Cac tang b phu thng to, mem va nang hn bnh thng, mau co the
nhat hoac am hn bnh thng; tren dien cat thng co dch phu chay ra. Mo di da b phu se
lom xuong khi an ngon tay vao. (Hnh 3 A, B)
b/ Vi the:
Mo ke b phu co hnh anh cua 1 cau truc long leo do ong dch phu. Trong phu phoi,
dch phu lam day vach phe nang va thoat vao trong long cac phe nang (Hnh 3C). Trong phu
nao, dch phu chen gia cac si than kinh va quanh cac mach mau.
Hnh 3: ai the va vi the cua phu mo di da chi di (A,B);

Phu phoi do suy tim, long phe nang dch phu mau hong (C).
II. SUNG HUYET

1. nh ngha
La tnh trang gia tang qua mc lng mau cha trong mo - c quan.
Phan biet 2 loai sung huyet
a/ Sung huyet ong (active hyperemia):
La s gia tang qua mc lng mau vao he thong mao mach do s gian n cac ong
mach va tieu ong mach. Nguyen nhan cua gian n nay co the do tac ong cua cac chat trung
gian hoa hoc (nh trong viem cap tnh) hoac do kch thch than kinh van mach. Sung huyet ong
se lam tang chuyen hoa te bao tai cho dan en s tang nhiet o, sung huyet ong mc o nang
co the gay ra phu do ong dch xuat thanh huyet. V vay cac mo - c quan b sung huyet ong
se co mau o rc, nong va sng.
Th du: o da trong viem da, o mat mac c.
b/ Sung huyet tnh (passive hyperemia= congestion):
Con goi la huyet, la tnh trang mau trong he mao mach va cac tieu tnh mach do s
dan lu mau tnh mach ve tim b can tr.
Cac mo - c quan b sung huyet tnh co mau o xam do mau ngheo oxy, sng to do
ong dch tham trong mo ke. Tnh trang thieu oxy co the dan en hoai t te bao - mo.
Sung huyet tnh thng gap nhat va co bieu hien ro ret nhat tai phoi va gan.
- Sung huyet tnh phoi: thng do

suy tim trai, hep van 2 la. Mau tnh mach
phoi ve tim b can tr lam phoi b sung
huyet; phoi co mau nau xam, ran. Di
KHV, cac mao mach cua vach phe nang
gian rong, thng co ton thng noi mo
lam thoat hong cau vao long phe nang. V
vay trong long phe nang co cac te bao
suy tim (heart failure cell) tc la cac ai
thc bao phe nang cha nhieu sac to
hemosiderin trong bao tng, ket qua cua
hoat ong phan huy hemoglobin cua hong
Hnh 4: A.Sung huyet tnh phoi keo dai, long phe nang
cau c thc bao. (Hnh 4) co cac te bao suy tim (mui ten). B. Te bao suy tim o
phong ai ln, bao tng ay hemosiderin.
- Sung huyet tnh gan: thng do suy tim phai, lam can tr s dan lu mau t tnh mach
tren gan ve tim. Ket qua gan sng to, mau o xam; khi cat ngang co hnh anh gan hat cau
(Hnh 5A), gom cac am tham mau (tng ng vi cac trung tam tieu thuy b huyet hoai t)
xen ke vi cac am nhat mau (tng ng vi cac vung te bao gan con bnh thng hoac thoai
hoa m). Di KHV, cac xoang mao mach gan gian rong do huyet; do tnh trang thieu oxy
trung tam tieu thuy nang hn vung quanh khoang ca nen cac te bao gan vung trung tam
thng b hoai t trc trong khi cac te bao gan quanh khoang ca van con tng oi bnh
thng hoac ch b thoai hoa m. (Hnh 5B)
Hnh 5: Hnh anh gan hat cau (A); tren vi the, hoai t te bao gan quanh tnh mach trung tam tieu thuy(*)
nang hn vung quanh khoang ca (mui ten) (B)
III. XUAT HUYET (hemorrhage):

1. nh ngha
La tnh trang mau toan phan thoat ra ngoai long mach.
2. Nguyen nhan
- Cac chan thng gay t v thanh mach.
- Benh ly thanh mach: phnh mach, x va ong mach, viem mach mau.
- Benh ly cam mau - ong mau: cac benh giam tieu cau mau, benh a chay mau.

Phan biet 2 loai xuat huyet:
a/ Xuat huyet ngoai: mau chay ra ngoai c the theo cac ng khac nhau: chay mau mui,
xuat huyet tieu hoa, chay mau ng sinh duc, v.v.
b/ Xuat huyet noi: mau thoat ra khoi long mach nhng van con nam trong c the. Mau co
the tch tu trong cac khoang t nhien gay ra tran mau mang tim, tran mau mang phoi, tran mau
mang bung, tran mau bao khp. Mau co the xam nhap vao cac mo di da va niem mac; bieu
hien di nhieu dang khac nhau nh om xuat huyet, ban xuat huyet, bam mau, o mau tu (Hnh
6).
Di KHV, bieu hien cua xuat huyet la s hien dien cua hong cau ben ngoai mach mau.
4/ Hau qua cua xuat huyet:
Tuy thuoc so lng mau b mat, toc o xuat huyet va v tr xuat huyet:
Th du: xuat huyet nhanh va nhieu ( > 20% the tch mau) co the gay ra tnh trang soc giam
the tch va t vong; cung lng mau mat nhng xuat huyet trong nao se co hau qua nang hn
xuat huyet di da.
Hnh 6: Cac om xuat huyet di niem mac ruot gia do benh giam tieu cau mau (A); xuat huyet di mang
cng do chan thng so nao (B).
IV. HUYET KHOI (thrombosis):

1. nh ngha
La s hnh thanh 1 cuc mau ong bat thng trong long he tuan hoan cua 1 ngi song
(tim, ong mach, tnh mach, mao mach); cuc mau nay luon dnh vao te bao noi mo va c goi
la cuc huyet khoi (thrombus).
Huyet khoi luon co lien quan vi 1 ton thng noi mo v chnh ton thng nay a khi phat
hoat ong cua he thong cam mau - ong mau a en s hnh thanh cuc huyet khoi.
2. Tom tat ve qua trnh cam mau - ong mau bnh thng (hnh 7):
ADP
Ser Thu Thay oi dang
TxA hut
Fibrinigen ADP
Ser
Tx
1. Ket dnh tieu cau 2. Nut tieu cau s cap
THROMBIN
BCN
Yeu to mo
HC Si Fibrin
4. Cuc mau ong 3. Nut tieu cau th cap
Hnh 7: Qua trnh cam mau ong - mau bnh thng
Te bao noi mo (TBNM) t nhien co tnh chong cam mau - ong mau v vay ngan can s
hnh thanh cuc mau ong trong long mach mau bnh thng.
- Khi TBNM b ton thng e lo mang ay va cac si collagen ben di, cac tieu cau (TC)
lap tc nhan biet, thay oi hnh dang, tho ra cac chan gia e bam vao v tr ton thng.
- S ket dnh vi collagen lam TC c hoat hoa va bat au phong thch ADP,
seretonin, Ca++, fibrinogen t cac hat trong bao tng ong thi tong hp mi thromboxane A2.
Phan t ADP, seretonin va thromboxane A2 co tac dung thu hut them cac TC khac en ket dnh,
ket qua hnh thanh 1 nut TC s cap khong ben bt len v tr ton thng.
- Mot phc hp phospholipid tren be mat TC hoat hoa se hoat hoa con ng ong mau
noi sinh, cac yeu to mo (tissue factor) san sinh t TBNM ton thng se hoat hoa con ng
ong mau ngoai sinh, ket qua thanh lap c thrombin.
- Thrombin xuc tac phan ng bien fibrinogen huyet tng thanh fibrin. Di tac ong cua
yeu to lam ben vng fibrin (yeu to XIII), cac phan t fibrin c trung hp vi nhau thanh si
fibrin, an ket thanh 1 mang li bao quanh nut TC, bien nut TC s cap thanh nut TC th cap
ben vng hn, co kha nang bt chac cho thng ton thanh mach e lam ngng xuat huyet. Neu
ton thng thanh mach qua ln, qua trnh ong mau se c tiep tuc, tao thanh 1 mang li
fibrin ln hn keo theo cac te bao mau vao trong cac mat li, ket qua hnh thanh 1 cuc mau
ong chong len nut TC e bt kn ton thng mot cach chac chan hn.
- Sau khi a lam ngng c xuat huyet, he thong tieu fibrin (plasminogen - plasmin) c
hoat hoa e lam tan nut TC va cuc mau ong, khoi phuc lai thanh mach va tai lap s lu thong
mau nh cu. (Hnh 8)
Hnh 8: Tieu cau bnh thng (mui ten, A); Tieu cau thay oi hnh dang (B); bam vao v tr ton thng (C);
hnh thanh nut tieu cau th cap (D); cuc mau ong chong len nut tieu cau th cap (E).
3. C che benh sinh

Co the xem huyet khoi la tnh trang benh ly cua qua trnh cam mau - ong mau bnh
thng bi v no dan en s thanh lap 1 cuc mau ong trong long mach nhng khong nham
muc ch cam mau. Cuc mau ong nay c goi la cuc huyet khoi, co the c thanh lap trong
cac trng hp sau:
- Ton thng noi mo cua he tim mach do nhoi mau c tim, viem noi tam mac, x va ong
mach, v.v.
- Roi loan huyet ong hoc: mau lu thong theo kieu xoay (trong phnh mach mau) hoac
qua cham chap (trong rung nh, sung huyet tnh) eu co the lam ton thng ve cau truc hoac
chc nang cua cac TBNM, thuan li cho s lang ong cac TC va fibrin tren be mat TBNM.
- Tnh trang mau tang ong: mau de ong hn bnh thng do mat can bang gia cac yeu
to ong mau va chong ong mau.
Cuc huyet khoi co the
xuat hien bat ky ni nao
trong he tim mach: buong tim,
ong mach, tnh mach, mao
mach. Trong buong tim va
cac ong mach ln co the
thay dang huyet khoi vach
mach do cuc huyet khoi ch
bam 1 ben vach. Cac cuc
huyet khoi ln trong buong
tim, ong mach chu hoac tnh
mach ln co dang phan lp
do s sap xep xen ke cac lp
TC mau trang vi cac lp HC
mau o, tao thanh cac ng
song song goi la ng Zahn
(Hnh 9). Huyet khoi trong cac
ong mach nho hn thng
gay nghen mach hoan toan
Hnh 9: Huyet khoi vach mach trong phnh ong mach chu bung (A);
hoac khong hoan toan. Huyet
Cuc huyet khoi co dang phan lp (B); gom cac lp tieu cau
khoi trong tnh mach luon luon
(mui ten) xen ke lp hong cau tao thanh ng Zahn (C)
gay nghen mach.
Hnh dang va kch thc cua cuc huyet khoi rat bien thien, t nhng khoi tron nho en
nhng khoi hnh tru dai va rat ln, nhng 1 ac iem khong the thieu la cuc huyet khoi luon co
1 chan gan vao thanh mach.
Di KHV, cuc huyet khoi cau tao bi nhieu am tieu cau, bao quanh bi mang li fibrin
trong o co nhieu bach cau va hong cau b mac ket trong cac mat li.
5. Hau qua cua huyet khoi

Khac nhau tuy theo v tr
va kch thc cua cuc huyet
khoi:
- Huyet khoi tnh mach gay
ra sung huyet tnh, co the a
en nhoi mau neu khong kp thi
co cac nhanh tnh mach khac
dan lu mau ra khoi vung b sung
huyet (Hnh 10).
- Huyet khoi ong mach
lam hep long mach, gay thieu
mau cuc bo vung mo tng ng;
Hnh 10: Huyet khoi tnh mach ui (A); Chan b sung huyet
co the dan en nhoi mau neu tac
tnh, phu, au do huyet khoi tnh mach sau chi di (B).
nghen hoan toan (Hnh 11A).
- Huyet khoi trong buong tim phai co the bong ra gay huyet tac phoi. Huyet khoi trong
buong tim trai bong ra gay huyet tac ong mach.
6. Tien trien cua cuc huyet khoi
- Tan hoan toan do hoat ong cua he thong tieu fibrin.
- Tiep tuc phat trien ln them.
- Di chuyen gay huyet tac.
- To chc hoa: cac te bao c trn va nguyen bao si tham nhap vao huyet khoi thong
qua cho bam vao thanh mach cua no, cac mao mach mi c hnh thanh. Mot lp te bao noi
mo mi c thanh lap phu len be mat cuc huyet khoi. Dan dan, cuc huyet khoi tr thanh 1 mo
lien ket di noi mo va c sat nhap vao thanh mach. oi vi cuc huyet khoi lam tac nghen
hoan toan long mach, s hnh thanh va thong noi gia cac mao mach tan tao trong cuc huyet
khoi co the tai lap c s lu thong mau. (Hnh 11B, C)
- Nhuyen hoa cuc huyet khoi: thng xay ra oi vi cuc huyet khoi ln, thay v c to
chc hoa, no lai tr nen mem nhun do tac ong cua cac enzym tieu the giai phong t cac bach
cau va tieu cau nam ket trong cuc huyet khoi. Cuc huyet khoi b nhuyen hoa la 1 moi trng
nuoi cay vi khuan ly tng, nhanh chong tr thanh khoi mu khi mau b nhiem khuan.
Hnh 11: ong mach b tac hoan toan bi cuc huyet khoi (A); Cuc huyet khoi c to chc hoa (B); xuat
hien cac mao mach tan tao (mui ten, C).
V. HUYET TAC (embolism)

1. nh ngha
La trng hp co 1 vat la b ay vao trong long mach, di chuyen theo dong mau roi ngng
lai ni ma ng knh long mach nho hn, khong cho phep no lot qua na. Vat la o c goi
la cuc huyet tac (embolus). Huyet tac ch xay ra trong he thong ong mach va mao mach,
khong bao gi thay he tnh mach.
2. Ban chat cua cuc huyet tac
- 99% la cac manh bong troc ra t cuc huyet khoi.
- 1% con lai co the la: manh x va cha cholesterol, giot m, kh, dch oi, am te bao
ung th, bong gon.
V vay, danh t huyet tac thng c ngam hieu nh huyet tac do huyet khoi
(thromboembolism), tr phi co ghi chu them nh huyet tac kh, huyet tac ung th, huyet tac dch
oi... (Hnh 12)
Hnh 12: Cuc huyet tac m (A); cuc huyet tac dch oi (B).
3. Hau qua cua huyet tac
Tuy theo kch thc va ban chat cuc huyet tac, v tr gay tac nghen mach, mc o tac
nghen, kha nang cung cap mau bang cac nhanh ben cho vung mo tng ng co mach mau b
nghen; huyet tac co the gay ra nhng hau qua rat khac nhau nh:
- Khong co bieu hien trieu chng neu cuc huyet tac nho, tan de dang do hoat ong cua
he thong tieu fibrin.
- Nhoi mau, hoai th.
- O viem hoac ap-xe tai ni nghen tac neu cuc huyet tac co mang vi khuan.
- O ung th di can neu cuc huyet tac la te bao ung th.
4. Phan loai huyet tac
Tuy theo huyet tac gay tac nghen cac ong mach trong he tieu tuan hoan hay ai tuan
hoan, co the phan biet 2 loai chnh: Huyet tac phoi va huyet tac ong mach.
a/ Huyet tac phoi (pulmonary embolism):
Hn 95% huyet tac phoi xuat
phat t huyet khoi tnh mach sau chi
di nh tnh mach chay, ui, hong;
5% con lai la do m, kh, nc oi, te
bao ung th ri vao tnh mach, i ve
tim phai roi len phoi (Hnh 13). Tuy
theo kch thc cuc huyet tac, v tr
ong mach phoi b nghen tac, hau qua
se khac nhau:
- Khong trieu chng neu cuc
huyet tac nho.
- Xuat huyet phoi.
- Nhoi mau phoi.
- ot t do suy tim phai cap, truy
tim mach (khi hn 60% he tieu tuan Hnh 13: Cuc huyet tac ln bong ra t huyet khoi tnh mach
hoan b nghen tac do co 1 cuc huyet sau chi di, i ve tim phai va len phoi, b ket lai cho chia
tac ln lam tac ong mach ln hay oi cua ong mach phoi (A); Vi the cuc huyet tac phoi cho
nhieu cuc nho lam tac nhieu nhanh thay ng Zahn (mui ten) (B).
ong mach nho).
b/ Huyet tac ong mach (arterial embolism, systemic embolism):

Hau het huyet tac ong mach xuat phat t huyet khoi vach buong tim, van tim ben tim
trai. Huyet tac ong mach luon a en nhoi mau c quan tng ng vi ong mach b tac
nghen. Cac c quan thng b huyet tac ong mach la chi di, tim, nao, than, lach, ruot.
VI. NHOI MAU (infarction) :
1. nh ngha
La tnh trang hoai t 1 vung mo - c quan do thieu mau cuc bo, gay ra bi s tac nghen
ong mach nuoi hoac tnh mach dan lu tng ng.
99% trng hp nhoi mau la do tac nghen ong mach. Tac nghen tnh mach t khi gay
nhoi mau v phan ln cac c quan trong c the thng co cac nhanh tnh mach ben giup dan lu
mau i, nh vay cai thien c tnh trang ti mau ong mach (tr phi c quan ch co 1 tnh
mach dan lu nh tinh hoan, buong trng, than).
2. Hnh thai nhoi mau
Da vao mau sac ai the, phan biet 2 loai nhoi mau sau:
a/ Nhoi mau trang:
Thng gap tim, lach, than, nao do cac ong mach nuoi (thuoc he mach mau tan cung)
b tac nghen.
O nhoi mau co mau vang nhat, mem, thng co hnh nem (nh tng ng vi ong
mach b tac, ay la phan ngoai vi cua c quan b nhoi mau), gii han ro va co mau o ti do
hien tng viem va xuat huyet vung mo lan can. Di KHV, o nhoi mau la 1 vung hoai t
ong ac, rieng oi vi nhoi mau nao th co dang hoai t hoa long. (Hnh 14)
Hnh 14: Nhoi mau trang than, co hnh nem, gii han ro (A); vi the la o hoai t ong ac (B);
b ro mau o la do hien tng viem va xuat huyet. Nhoi mau trang lach, co hnh nem (D).
b/ Nhoi mau o:
Nhoi mau o xay ra do tac ong mach nhng c quan c nuoi dng bi he tuan
hoan kep (th du: phoi co he ong mach phoi va ong mach phe quan), hoac co he thong mach
ben phong phu (th du: ruot); ket qua la du co tac nghen ong mach nhng mau van c a
en vung ton thng bi cac ong mach con lai.
Hnh 15: Nhoi mau o cc tren thuy di phoi (mui ten, A); vi the la o hoai t ong kem xuat
huyet (B). Nhoi mau o tinh hoan do xoan thng tinh lam tac tnh mach dan lu duy nhat (C).
O nhoi mau co gii han ro, mau o; hnh anh vi the la mot vung hoai t ong co kem
xuat huyet. Cac o nhoi mau phoi de b boi nhiem cac vi khuan (lot vao qua ng ho hap) va
co the bien thanh 1 o mu (Hnh 15A,B).
Nhoi mau o cung co the xay ra do tac tnh mach nhng c quan ch c dan lu bi
mot tnh mach duy nhat (th du: tinh hoan, buong trng, than). Khi tnh mach duy nhat nay b tac,
mau tnh mach khong thoat ra c, can tr s ti mau ong mach; ket qua c quan b sng
phong huyet va hoai t. Hnh anh vi the cung la mot vung hoai t ong kem xuat huyet (Hnh
15C).
3. Dien tien cua cac o nhoi mau

Co s xuat hien phan ng viem tai vung hoai t. Qua trnh sa cha tiep theo se bien o
hoai t thanh 1 mo seo. oi vi nhoi mau nao, hoai t hoa long se bien o nhoi mau thanh 1
boc cha dch long.
4. Hau qua cua nhoi mau

Tuy thuoc v tr va kch thc cua o nhoi mau. Nhoi mau c tim, nhoi mau nao, nhoi mau
phoi, nhoi mau ruot eu la nhng ton thng co the a en t vong.
VII. SOC (shock):

1. nh ngha
Soc la 1 tnh trang roi loan huyet ong va chuyen hoa tram trong ma ac trng la s suy
yeu cua he tuan hoan khong con am bao s ti mau ay u cho cac c quan. Hau qua la cac
te bao va mo se b ton thng do thieu oxy va chat dinh dng. Cac ton thng nay luc au con
kha hoi nhng neu khong c ieu tr kp thi, se chuyen sang giai oan bat kha hoi lam chet
te bao va gay t vong cho benh nhan.
2. C che benh sinh
S giam ti mau trong soc la ket qua cua s giam cung lng tim. Co 2 c che lam giam
cung lng tim la giam sc co bop cua tim va giam the tch tuan hoan; da theo o phan biet 2
loai soc chnh:
a/ Soc do tim: cung lng tim giam do chc nang co bop cua tim b suy giam, thng gap
trong nhoi mau c tim, huyet tac phoi, viem c tim, chen ep tim, loan nhp tim nang.
b/ Soc do giam the tch tuan hoan: the tch tuan hoan giam do that thoat dch t long
mach ra ngoai c the hoac trong c the
- Ra ngoai c the: xuat huyet ngoai, tieu chay, mat nc do a nieu, tiet mo hoi.
- Trong c the: nhiem oc mau vi noi oc to vi khuan (soc noi oc to), bong, chan
thng, d ng (soc phan ve).
Trong ca hai loai soc tren, s giam cung lng tim se lam giam ti mau mo, ket qua cac
te bao se b ton thng do thieu oxy. Ton thng te bao noi mo lam tang tnh tham thanh mach
va tang that thoat dch ben trong c the; ket qua la the tch tuan hoan va cung lng tim cang
giam, cang lam nang them ton thng te bao do thieu oxy. Mat khac, s thieu oxy lam te bao
phai chuyen t chuyen hoa ai kh sang chuyen hoa k kh, dan en s ong acid lactic va tnh
trang nhiem toan chuyen hoa. Tnh trang nhiem toan nay lam gian cac tieu ong mach, gay
ong mau trong he vi tuan hoan va giam sc co bop c tim, ket qua the tch tuan hoan va cung
lng tim lai giam them na. Nh vay 1 vong quan a c hnh thanh: s ti mau mo cang
luc cang giam va ton thng te bao - mo do thieu oxy cang luc cang tang. (hnh 16)
3. Hau qua cua soc

Cac ton thng te bao va mo do soc co the thay moi c quan nhng ro ret nhat la
nao, tim, phoi, than, thng than va ng tieu hoa di dang cac om xuat huyet, hoai t nhu
mo. Hau het cac c quan nay eu co the hoi phuc tr lai bnh thng neu benh nhan c ieu
tr kp thi trong giai oan soc con kha hoi (tr cac ton thng nao va tim nh hoai t nron,
hoai t te bao c tim la khong hoi phuc c). Khi soc a bc sang giai oan bat kha hoi, te
bao va mo b ton thng nang, chc nang cac c quan sinh t b suy sup dan en t vong
cho benh nhan.
SOC GIAM THE TCH

That thoat ben trong That thoat ben ngoai SOC TIM
Noi oc to Xuat huyet
Nhoi mau c tim
Bong Tieu chay
Viem c tim
Chan thng Mat nc
Tang tham Giam the tch Giam cung Giam sc

thanh mach Tuan hoan ln g tim co bop tim
mau vi tuan hoan

Giam ti
Toan chuyen hoa mau mo
C tim thieu ATP
Ho hap k kh
Ton thng te bao
Ton thng te bao
noi mo
do thieu Oxy
Hnh 16: C che benh sinh cua soc
1. S hien dien cua hong cau ben ngoai mach mau c goi la hien tng:
A/ Sung huyet ong B/ Sung huyet tnh C/ Xuat huyet
D/ Huyet tac E/ Huyet khoi
2. Nhoi mau trang khong gap :

A/ Tim B/ Phoi C/ Than D/ Nao E/ Lach
3. ac iem hnh thai bat buoc phai co moi cuc huyet khoi la:
A/ Co ton thng noi mo B/ Co roi loan huyet ong hoc
C/ Co tnh trang tang ong mau D/ Co chan gan vao thanh mach
E/ Ca A, B, C, D ung
4. Huyet tac phoi co the xay ra do:

A/ Huyet khoi tnh mach sau chi di B/ Huyet khoi buong tim phai
C/ M, kh, nc oi, te bao ung th theo tnh mach ve tim phai roi len phoi
D/ Ch A va C ung E/ Tat ca A, B, C eu ung
5. C che hnh thanh phu khong do viem :

A/ Tang ap lc thuy tnh B/ Giam ap lc tham thau keo cua huyet tng
C/ Tang tnh tham thanh mach D/ Ch A, B ung E/ Ch A, B, C ung
6. Mot san phu hoan toan khoe manh, sau khi sinh thng th ot nhien b kho th, tm tai, co
giat, hon me va t vong. Nhieu kha nang nhat se tm thay trong ong mach phoi:
A/ M B/ Manh x va C/ Dch oi
D/ Nut tieu cau E/ Huyet tac ung th
GIAI PHAU BENH CHUYEN BIET
Bnh l H Tim Mch 111
BENH HE TIM MACH
Muc tieu:
1. Ke ten cac loai benh ly tim va mach mau thng gap: x cng ong mach, cao
huyet ap, suy tim, nhoi mau c tim, viem noi tam mac nhiem khuan va thap tim.
2. Nam vng dnh ngha, cac yeu to nguy c, hnh thai ton thng, c che hnh thanh,
dien tien va bien chng cua tng loai benh.
BENH LY MACH MAU

NHAC LAI MO HOC: So sanh gia ong mach va tnh mach cung cap, ong mach (M)
co thanh day hn e chu c mot ap lc mau cao hn; trai lai, tnh mach (TM) co ng knh
tng oi ln hn, long mach rong hn va thanh mong hn. Cau truc chung cua thanh mach
gom 3 lp ong tam: ao trong, ao gia va ao ngoai.
Da vao ng knh (k) va 1 so ac iem mo hoc, phan biet:
- ong mach ln tc cac ong mach chun, th du nh M chu,m co, M di on, M
chau va M phoi.
- ong mach trung bnh tc cac M c, th du nh M vanh tim.
- ong mach nho, k < 2mm, la cac m nam trong cac mo - c quan.
- Tieu ong mach, co k 20-100mcm.
- Mao mach co thanh ch gom 1 lp te bao noi mo ta len mang ay.
ong mach, ao trong gom 1 lp te bao noi mo, da tren 1 mo lien ket mong; ao trong
c gii han vi ao gia bang 1 mang chun day goi la mang ngan chun trong, co cac ca so
qua o cac te bao c trn cua ao gia co the di chuyen t ao gia vao ao trong. Ao gia gom
cac la chun oi vi M chun, hoac cac lp c trn xep vong oi vi M c. Ao ngoai la 1 lp
mo lien ket mong, co cha cac si than kinh va cac mach nuoi mach (vasa vasorum). 1/3 trong
cua thanh mach c nuoi dng bi oxygen va cac chat dinh dng tham trc tiep t mau
trong long mach; 2/3 ngoai do mach nuoi mach cung cap.
I. BENH X CNG ONG MACH (arteriosclerosis):

La 1 nhom benh co ac iem chung la thanh mach mau day len va mat tnh an hoi.
Phan biet 3 loai:
- X va ong mach: la loai thng gap nhat va quan trong nhat.
- Hoa voi ao gia ong mach.
- X cng tieu ong mach.
A. X VA ONG MACH ( atherosclerosis)
1. nh ngha
Benh x va ong mach (XVM) xay ra cac ong mach c ln va trung bnh, t thay
cac ong mach nho co ng knh < 2mm. Ton thng c ban cua benh XVM la cac vung day
len cua lp ao trong, goi la mang x va (fibrolipid plaque). Cac mang x va luc au con nho
va tha tht, dan dan tang kch thc gay ra hep long mach .
2. Cac yeu to nguy c
Benh XVM rat pho bien cac nc phat trien, la nguyen nhan cua hn 50% cac trng
hp t vong hang nam My. Cac ieu tra dch te hoc a xac nh c mot so yeu to nguy c
lam de mac benh XVM nh sau:
- Cac yeu to chnh: tang cholesterol mau, cao huyet ap, hut thuoc la, benh tieu ng.
- Cac yeu to phu: beo ph, t hoat ong the lc, nam gii, tuoi cao, stress, dung thuoc
nga thai, an qua nhieu ng, v.v.
Bnh l H Tim Mch 112
a/ ai the: Mang x va co hnh bau duc, mau trang hay vang nhat; kch thc t 0,3 -1,5
cm; nam rai rac doc theo chieu dai cua ong mach. Mang x va thng thay ong mach
chu, ong mach nao, ong mach vanh tim, ong mach co, ong mach mac treo, ong mach
chau, ong mach ui. (Hnh 1)
Hnh 1: Cac mang x va ong mach chu ngc (A), ong mach chu bung (B)
b/ Vi the:
Mang x va nam trong lp ao trong cua thanh mach, khi cat ngang thay co 2 thanh phan
(Hnh 2):
Hnh 2: Cau tao mang x va

Bnh l H Tim Mch 113
- Thanh phan mu si (fibrous cap): nam tren be mat, la 1 mo lien ket ac giau si
collagen, c phu ben tren bi lp te bao noi mo; gia cac si collagen co cac te bao c trn,
ai thc bao, limpho bao.
- Trung tam va nhao (atheroma): la 1 khoi lay nhay nh chao va mau vang nam ben
di mu si, cau tao bi lipid va cholesterol. Cac phan t cholesterol co the ket tu thanh nhng
tinh the hnh kim; ngoai ra tai ay con co cac manh vun te bao hoai t, cac ai thc bao cha
ay khong bao m trong bao tng (con goi la te bao bot hay bot bao). (Hnh 3, 4)
vung ngoai vi cua mang x va co the thay nhieu mach mau tan sinh.
Hnh 3: Mang x va vi 2 thanh phan
Hnh 4: Trung tam va nhao cha tinh the cholesterol (1) va te bao bot (2)
4. C che hnh thanh mang x va:

Van con la gia thuyet, theo o ton thng khi au cua benh XVM la 1 ton thng ve
cau truc hoac chc nang cua cac te bao noi mo di tac ong keo dai cua cac yeu to nguy c
a neu tren. Ton thng te bao noi mo dan en s tang tnh tham oi vi cac thanh phan trong
huyet tng nh lipid va cholesterol, tang ket dnh cac tieu cau va gia tang s xuyen mach cua
Bnh l H Tim Mch 114
cac mono bao. Ket qua la co s gia tang so lng ai thc bao va s lang ong lipid va
cholesterol trong lp ao trong cua thanh ong mach. Cac ai thc bao bien thanh te bao bot do
nhap bao qua mc lipid va cholesterol.
Mat khac, cac yeu to tang trng nh PDGF va TGF beta; c tiet ra bi cac te bao noi
mo, tieu cau va ai thc bao; se kch thch cac te bao c trn di chuyen t lp ao gia vao lp
ao trong va tien hanh phan bao tai ay. Cac te bao c trn se thay oi t kieu hnh "co duoi"
thanh kieu hnh "tong hp - tang sinh", san xuat cac si collagen va si chun, tao thanh mu si
cua mang x va. Mu si can tr s khuyech tan cua oxy va cac chat dinh dng t long mach
vao lp ao trong, lam cac te bao bot b hoai t, ket qua hnh thanh khoi va nhao trung tam
mang x va. Mang x va chen ep pha v mang ngan chun trong va lam teo mong lp ao gia
cua thanh mach. (Hnh 5 va 6)
Hnh 5: C che hnh thanh mang x va (A), cac te bao ong lipid (*) tap trung trong lp ao trong (B), cac
te bao c trn di chuyen vao lp ao trong, tang sinh va thay oi kieu hnh
Hnh 6: Mang x va (MXV) chen ep lam teo mong ao gia (AG) thanh mach.
Bnh l H Tim Mch 115
5. Dien tien cua mang x va va cac hau qua:
Mang x va sau khi c hnh thanh se ln dan va co the chu them cac bien oi sau:
- Loet hoac nt v be mat mang x va (Hnh 7A), lam chat va nhao trung tam b rt
vao long mach tao thanh cuc huyet tac cholesterol. (Hnh 7B)
- Xuat huyet ben trong mang x va (Hnh 7C): do mau t long mach chui vao qua cho nt
v tren be mat, hoac do v cac mach mau tan sinh trong mang x va. Ket qua mang x va b
phnh to, lam hep them long mach.
- Huyet khoi: ton thng te bao noi mo be mat mang x va do loet se gay ket dnh tieu
cau, dan en s hnh thanh huyet khoi (Hnh 7D). Cuc huyet khoi nay co the bong vao long
mach va tr thanh cuc huyet tac.
- Calci hoa: cac te bao hoai t kch thch s lang ong calci trong mang x va, lam cho
thanh ong mach tr nen cng don de v. (Hnh 7E)
Hnh 7: Mang x va b loet be mat (A), tao cuc huyet tac cholesterol (B),
xuat huyet trong mang x va (C), tao huyet khoi (D), lang ong calci (E)
Bnh l H Tim Mch 116
- Mac dau ton thng ban au cua benh XVM la cac mang x va thuoc ve lp ao
trong, nhng khi mang x va nay ln dan, no se chen ep lam teo mong lp ao gia thanh mach
(Hnh 6). S mat i cac te bao c trn va cac si chun va thay vao o la cac si collagen khong
an hoi se lam cho thanh mach suy yeu, de b v hoac phong ra thanh tui phnh ong mach sau
nhieu nam.
Cac hau qua do mang x va gay ra rat a dang, gom co cac tnh trang thieu mau cuc
bo, nhoi mau, hoai th vung mo - c quan tng ng vi mach mau b nghen tac; hoac xuat
huyet noi do v mach mau...
B. HOA VOI AO GIA ONG MACH (medial calcific sclerosis):
Con goi la benh Monckeberg, thng gap ngi gia (hiem gap trc 50 tuoi), cha ro
nguyen nhan gay benh.
Hnh thai ton thng: co s lang ong calci trong lp ao gia cua cac ong mach, khong
co phan ng viem kem theo, lp ao trong va ao ngoai khong b ton thng, long mach khong b
hep lai. Thng gap ong mach ui, ong mach chay, ong mach quay, ong mach tru. (Hnh
8)
Hnh 8: Mot ong mach c b hoa voi ao gia kem vi ton thng x va
C. X CNG TIEU ONG MACH

Phan biet 2 loai:
1. X cng tieu ong mach hyalin (hyalin arteriolosclerosis):
Thng gap nhng ngi ln tuoi va ngi mac benh cao huyet ap nhe.
Hnh thai ton thng: co s lang ong chat hyalin di lp te bao noi mo, lam day thanh
mach va hep long mach, co the gay ra thieu mau cuc bo cho vung mo-c quan tng ng. Than
thng la c quan b tac ong nhieu nhat, tnh trang x cng cac tieu ong mach en cua cau
than cuoi cung se lam hyalin hoa cau than, teo ong than va x hoa mo ke. C che gay ra x
cng tieu ong mach hyalin co the la do cao huyet ap lam ton thng te bao noi mo, dan en
s thoat cac chat trong huyet tng vao trong thanh mach (Hnh 9).
Bnh l H Tim Mch 117
Hnh 9: X cng tieu ong mach hyalin lach (A) va tieu ong mach en va i cua cau than (B)
2. X cng tieu ong mach tang san (hyperplastic arteriolosclerosis)

Thng gap trong benh cao huyet ap ac tnh.
Hnh thai ton thng: cac te bao c trn tang san tao thanh cac la xep ong tam tng
t cu hanh cat ngang, lam thanh mach day len va hep long mach, dan en thieu mau cuc bo
vung mo - c quan tng ng. C che co the do te bao noi mo b ton thng v cao huyet ap ac
tnh, se san xuat ra cac yeu to tang trng kch thch s tang san te bao c trn. i cung vi s
tang san nay, thng co s lang ong chat dang fibrin (fibrinoid) kem phan ng viem cap tnh
gay hoai t thanh mach, goi la viem tieu ong mach hoai t. X cng tieu ong mach tang san
va viem tieu ong mach hoai t co the xay ra cho moi mo c quan trong c the; nhng than van
la c quan b tac ong nhieu nhat, co the dan en suy than. (Hnh 10)
Hnh 10: X cng tieu ong mach tang san (A), viem tieu ong mach hoai t (B)
II. CAO HUYET AP (hypertension)

1. nh ngha
Cao huyet ap (CHA) la nguyen nhan gay suy tim thng gap nhat; no cung la yeu to
nguy c chnh dan en benh x va ong mach va xuat huyet nao. CHA c nh ngha la tnh
trang huyet ap 160/95 mmHg, va c phan thanh 3 mc o da theo huyet ap tam trng:
- CHA nhe: huyet ap tam trng trong khoang 95 - 104 mmHg
- CHA va: huyet ap tam trng trong khoang 105 - 114 mmHg
- CHA nang: huyet ap tam trng > 115 mmHg
2. Phan loai
Da theo nguyen nhan, phan biet 2 loai CHA:
- CHA nguyen phat, con goi la cao huyet ap vo can v khong tm thay nguyen nhan ro
ret, chiem 90% cac trng hp CHA, thng xay ra sau 40 tuoi.
Bnh l H Tim Mch 118
- CHA th phat, chiem 10% cac trng hp CHA, co nguyen nhan ro ret nh benh ly
than (suy than man, viem cau than cap, hep ong mach than), that hep ong mach chu, u
tuyen thng than. CHA th phat co the xay ra moi la tuoi.
Da theo dien tien lam sang, CHA (nguyen phat hoac th phat) c phan thanh 2 loai:
- CHA lanh tnh: huyet ap tang t t trong nhieu nam ma khong co trieu chng lam sang,
benh c phat hien tnh c khi o huyet ap.
- CHA ac tnh: huyet ap tang nhanh trong thi gian ngan (huyet ap tam trng > 120
mmHg); gay ra cac trieu chng than kinh, tim mach,...Benh nhan t vong trong vong 1-2 nam
neu khong c ieu tr.
3. C che benh sinh cua benh CHA nguyen phat (Hnh 11)
Tr so huyet ap c quyet nh bi 2 thong so huyet ong hoc la cung lng tim va
khang lc mach ngoai vi; huyet ap tang khi 2 thong so nay tang cao. Tuy cha hoan toan hieu
ro, cac yeu to sau ay c cho la co vai tro trong c che benh sinh cua CHA nguyen phat:
- ong natri: co s suy giam bai tiet Natri tai than, gay natri trong c the, ket qua la
the tch mau va cung lng tim tang. Cung lng tim tang se lam tang huyet ap.
- Tang lng catecholamin trong mau va tang tnh nhay cam cua cac te bao c trn thanh
mach oi vi catecholamin; ong thi co s roi loan van chuyen natri va calci ngang qua mang
te bao, lam tang nong o calci noi bao. Ket qua la c trn thanh mach co lai, lam tang khang
lc mach ngoai vi.
- Tang lng renin giai phong t bo may can cau than, renin xuc tac phan ng bien
angiotensinogen (la mot globulin huyet tng) trong mau thanh angiotensin I, angiotensin I c
chuyen thanh angiotensin II tai phoi nh tac ong cua enzym chuyen angiotensin ACE
(Angiotensin converting enzyme). Angiotensin II tac ong trc tiep len te bao c trn thanh
mach, gay co mach manh; ong thi lai tac ong len vo thng than, kch thch s che tiet
aldosteron, lam tang tai hap thu natri va nc ong than xa. Ket qua la khang lc mach ngoai
vi va the tch tuan hoan eu tang len.
Hnh 11: C che benh sinh CHA
4. Hnh thai ton thng cua cac mach mau trong benh CHA
Trong CHA lanh tnh, thng gap ton thng x cng tieu ong mach hyalin. Trai lai, trong
CHA ac tnh, thng gap x cng tieu ong mach tang san va viem tieu ong mach hoai t.
5. Hau qua
Hau qua cua CHA rat a dang nhng ang chu y nhat la 4 loai mo c quan sau:
- Tim: tam that trai ph ai e thch nghi vi tnh trang tang huyet ap (Hnh 12A). Neu
huyet ap tiep tuc tang vt qua kha nang thch nghi cua tim, tam that trai se b phnh gian a
en suy tim. CHA lam ton thng x va nang hn, lam giam tuan hoan mach vanh tim, gay ra
benh thieu mau c tim hoac nhoi mau c tim.
Bnh l H Tim Mch 119
- Nao: benh nhan CHA de b xuat huyet nao do thanh mach don, de v (Hnh 12B).
- Than: ca 2 loai x cng tieu ong mach trong benh CHA eu co the gay ra thieu mau
cuc bo than, lam cac cau than va ong than b teo et dan, dan en suy than man tnh.
- ong mach chu: CHA thuan li cho s hnh thanh cac mang x va, phnh mach va
phnh mach tach.
Hnh 12: Ph ai that trai do cao huyet ap (A), xuat huyet nao vao nao that (B)
III. VIEM ONG MACH

Co nhieu loai viem ong mach khac nhau, cap tnh hoac man tnh.
Nguyen nhan a dang: vi khuan, virut, ky sinh trung, nam moc, cac tac nhan ly hoa, phan
ng qua man; mot so trng hp con cha ro nguyen nhan.
Hnh thai ton thng chung cua cac benh viem ong mach la co s tham nhap cac te bao
viem cap hoac man trong thanh mach; ca 3 lp ao cua thanh mach eu co the b hoai t dan
en cac bien chng nh tac mach, phnh mach hoac v mach.
Sau ay la 2 loai viem ong mach thng gap:
1. Benh viem ong mach thai dng (temporal arteritis):

La loai viem ong mach thng gap nhat, ch xay ra ngi ln tuoi (hiem gap trc 50
tuoi), gii n mac benh nhieu hn gii nam gap 2-3 lan. Ton thng xay ra chu yeu cac ong
mach vung au co nh ong mach thai dng, ong mach mat. Nguyen nhan cha biet ro, co
the do phan ng qua man chong lai elastin cua thanh mach. Bieu hien lam sang gom nhc au,
roi loan th giac, o va au doc theo ng i cua ong mach, co the co au c kem theo. ang
s nhat la bien chng mu ot ngot do ton thng ong mach mat.
Hnh thai ton thng:
ong mach cng nh day thng, co cho day len thanh not, long mach b thu hep do s
day len va hoa si cua lp ao trong. Mang ngan chun trong b hoai t v vun, canh o co s tap
trung cac ai bao nhieu nhan, limpho bao, tng bao va mo bao; tao nen hnh anh cua 1 viem
hat. (Hnh 13A, B)
Hnh 13: Viem ong mach thai dng,

long mach thu hep do lp ao trong day
len va hoa si (A), mang ngan chun
trong v vun, tap trung te bao viem va
ai bao (B).
Bnh l H Tim Mch 120
2. Benh Buerger (Buergers disease, thromboangiitis obliterans)
La loai viem ong mach co lien quan vi tat nghien hut thuoc la, do o hau nh ch xay ra
an ong, thng trong la tuoi 25-50. Ton thng chu yeu cac ong mach cua chi tren va
chi di (ong mach quay va ong mach chay). Moi lien quan gia benh va thuoc la c thay
ro qua s giam benh khi ngng hut thuoc; c che co the do khoi thuoc co cha cac chat hoac
gay oc trc tiep cho cac te bao noi mo hoac co the kch thch 1 phan ng qua man chong lai
cac te bao nay.
Hnh thai ton thng: co s tham nhap cac te bao viem cap, hnh thanh cac o ap xe nho
trong thanh mach; cac te bao noi mo b ton thng co the dan en s hnh thanh cac huyet khoi
lam tac mach, gay hoai t hoai th cac au chi. (Hnh 14)
Hnh 14: Benh Buerger, gay hoai t hoai th au ngon chan; long ong mach b tac do huyet khoi, co cac o
ap xe nho trong thanh mach (mui ten)
IV. PHNH MACH (aneurysm):

La s phnh gian bat thng 1 vung cua ong mach, gay ra bi s suy yeu lp ao gia
thanh mach.
Nguyen nhan gay suy yeu lp ao gia thanh mach co the la 1 khuyet tat bam sinh, hoac
do nhiem khuan, XVM, chan thng.
Da vao hnh dang va kch thc, phan biet cac loai phnh mach sau:
- Phnh mach dang tui: tui phnh hnh cau, ch lien quan en 1 phan chu vi cua thanh
mach, ng knh t 5 - 20 cm.
- Phnh mach hnh thoi: tui phnh lien quan en toan bo chu vi thanh mach, kch thc thay
oi, co the en 20 cm.
- Phnh mach hnh qua dau: hnh dang tng t phnh mach hnh tui nhng co kch thc
nho, hiem khi ng knh vt qua 1 - 1,5 cm; gap chu yeu cac ong mach nao, nhat la vong
ong mach Willis.
Hnh 15: Phnh ong mach chu dang tui (A) va hnh thoi (B)
Bnh l H Tim Mch 121
Phnh mach phat trien ln dan co the chen ep len cac mo - c quan lan can lam can tr
hoat ong cua cac mo - c quan nay, hoac v ra gay xuat huyet o at; v vay phnh mach ac
biet nguy hiem neu xuat hien ong mach chu va ong mach nao.
1. Phnh ong mach chu:
Do 3 nguyen nhan chnh: XVM, thoai hoa ao gia dang boc, benh giang mai thi ky th
3.
- Phnh ong mach chu do benh XVM: la loai phnh mach thng gap nhat, co dang tui
hoac hnh thoi, thng xuat hien ong mach chu bung, oan di cho phan nhanh ra ong
mach than. C che gay phnh mach la do mang x va lam teo mong ao gia khien thanh mach
b suy yeu.
- Phnh ong mach chu do benh giang mai: hien nay t gap, tui phnh thng xuat hien
cung ong mach chu va ong mach chu ngc. C che gay phnh mach la do phan ng viem
gay ra bi xoan khuan giang mai lam tac nghen cac mach nuoi mach, ket qua lp ao gia b
hoai t do thieu mau nuoi, lam thanh mach suy yeu.
- Phnh ong mach chu do thoai hoa ao gia dang boc: thng xuat hien cung ong
mach chu va ong mach chu ngc; trong lp ao gia xuat hien cac boc cha ay mot chat nhay
vo nh hnh (tng t chat can ban cua mo lien ket) lam cac la si chun trong lp ao gia b
thoai hoa v vun; ket qua thanh mach b suy yeu (Hnh 16). ang s nhat la cac boc nay co the
thong noi vi nhau va vi long mach dan en s hnh thanh o mau tu boc tach gia thanh mach
(dissecting intramural hematoma), con goi la phnh mach tach (dissecting aneurysm), co the v
ra gay xuat huyet o at. (Hnh 16)
Hnh 16: Thoai hoa ao gia dang boc (A,B), cac boc cha chat nhay (*);
co the thong noi tao thanh o mau tu boc tach gia thanh mach.
Bnh l H Tim Mch 122
2. Phnh ong mach nao
Co the do nguyen nhan khuyet tat bam sinh hoac XVM.
- Phnh ong mach nao do khuyet tat bam sinh thng xuat hien cac chac ba ong mach
cua vong ong mach Willis, tui phnh co dang qua dau. C che la do thanh mach cac chac ba
nay b thieu hut bam sinh lp c; ket qua thanh mach b suy yeu, de phnh ra do lc ay cua
dong mau (Hnh 17).
Hnh 17: Phnh mach hnh qua dau ong mach nao
- Phnh ong mach nao do XVM thng xuat hien cac ong mach nao ln hn nh
ong mach ay, ong mach nao gia; tui phnh thng co dang hnh thoi.
V. BENH TRNG N TNH MACH (varicose veins):

La tnh trang tnh mach b trng n bat thng do s gia tang ap lc trong long mach.
Thng gap tnh mach nong chi di (do t the), tnh mach thc quan va tnh mach hau mon
(do tang ap lc tnh mach ca trong x gan). (Hnh 18)
Hnh thai ton thng:

Tnh mach trng n chay ngoan ngoeo, thanh
tnh mach day mong khong eu do co s tang san
cac te bao c trn cua lp ao gia va hoa si cua lp
ao trong, thng co s thanh lap huyet khoi trong
long mach va bien dang van tnh mach. Hau qua cua
benh trng tnh mach chi di la tnh trang sung
huyet tnh, mau lu thong kem lam roi loan dinh
dng da; da de b viem, l loet lau khoi.
Hnh 18: Trng n tnh mach nong chi di do t the

Bnh l H Tim Mch 123
VI. U MACH MAU
1. U lanh mach mau (hemangioma):
Thng thay tre em. U co the xuat hien da, niem mac hoac trong cac tang nh gan,
lach, than. Kch thc u thay oi t vai mm en vai cm, mau o hoac xanh, phang hoac go cao
hn be mat da. Da vao hnh thai vi the, co the phan biet 2 loai chnh thng gap sau ay:
- U lanh mach mau dang mao mach: u c cau tao bi cac mach mau co cau truc va
kch thc giong cac mao mach bnh thng.
- U lanh mach mau dang hang: u cau tao bi cac khoang ln cha ay mau, ngan cach
nhau bang cac vach lien ket mong. Khoang c lot bi cac te bao noi mo; thng co cac cuc
huyet khoi do s lu thong mau trong khoang b roi loan. (Hnh 19)
Hnh 19: U lanh mach mau da tran (A), vi the co dang mao mach (B) hoac dang hang (C)
2. Sarcom mach mau (angiosarcoma):

La 1 loai u ac rat hiem gap, ton thng khi au la cac not nho, mau o, khong au; xuat
hien tren da hoac cac noi tang nh gan, lach. U phat trien ln dan tao thanh 1 khoi ln mau
xam, mem; thng co hoai t va xuat huyet, co the cho di can en hach bach huyet. Ve mat vi
the, u cau tao bi cac te bao noi mo tang sinh ac tnh. Tuy theo o biet hoa, cac te bao u co the
tao ra nhng khoang nho tng t long mach, hoac ch tap hp thanh cac am te bao noi mo ac
tnh day ac. (Hnh 20)
Hnh 20: Sarcom mach mau tren da vu (A); Vi the chi thay cac te bao noi mo d dang (mui ten, B).
Bnh l H Tim Mch 124
BENH LY TIM
I. SUY TIM (cardiac failure)
Tim la mot may bm hoan hao, can nang khoang 250 - 350 gr. Moi nam tim co bop 42
trieu lan, ay vao long mach khoang 2,6 trieu lt mau. Suy tim xay ra khi chc nang co bop cua
tim b suy giam, khong con ap ng c nhu cau chuyen hoa cua c the. Trong giai oan au,
goi la giai oan suy tim con bu, benh nhan co the cha co trieu chng ro ret nh vao nhng ap
ng thch nghi cua c the nh tang hoat ong he than kinh giao cam va ph ai c tim. Khi cac
ap ng thch nghi khong con hieu qua, benh nhan chuyen sang giai oan suy tim mat bu vi
ay u cac trieu chng cua suy tim.
Suy tim c phan biet thanh 3 loai:

- Suy tim trai: thng do cao huyet ap, benh van tim 2 la va van ong mach chu, benh c
tim. Mau lai trong he tieu tuan hoan gay ra phu phoi, lam benh nhan tm tai kho th. (Hnh 21)
Hnh 21: Ph ai that trai do cao huyet ap (A), phu phoi do suy tim trai (B)
- Suy tim phai: thng th phat sau suy tim trai, cung co the xay ra nhng benh nhan
khong suy tim trai nhng co benh ly nhu mo va mach mau phoi, hoac benh ly cua van 3 la va
van ong mach phoi. Mau lai trong he tuan hoan ngoai bien gay ra phu ne mo mem di da,
gan to, tran dch a mang. (Hnh 22)
Hnh 22: Ph ai va gian that phai do benh x phoi (A), gan to do mau co hnh anh hat cau
- Suy tim toan bo: khi ca tim trai va tim phai cung b suy. (Hnh 23)
Ngoai ra, ngi ta con phan biet suy tim theo dien tien lam sang thanh 2 loai: suy tim cap
(gap trong nhoi mau c tim, cao huyet ap ac tnh, huyet tac phoi) va suy tim man.
Bnh l H Tim Mch 125
Hnh 23: Tim bnh thng (A); tim b day that trai (B); suy tim toan bo ca 2 that eu b gian (C)
II. NHOI MAU C TIM ( myocardial infarction):
1. nh ngha: la tnh trang hoai t 1 vung c tim do thieu mau nuoi dng, vung c tim hoai t
c goi la o nhoi mau c tim (myocardial infarct).
2. Nguyen nhan: hau het cac trng hp nhoi mau c tim (NMCT) la do ong mach vanh b tac
nghen bi mang x va (Hnh 24); mot t trng hp khong thay co ton thng x va va c
giai thch la do s co that keo dai cua ong mach vanh tim.
Hnh 24: Mang x va lap bt lo vao ong mach vanh

O NMCT co kch thc thay oi t 4-10 cm, xuat hien chu yeu tam that trai va vach lien
that, hiem khi thay tam that phai. Tuy theo nhanh ong mach vanh nao b tac nghen, v tr cua
o NMCT tren that trai se khac nhau (Hnh 25):
- Tac nhanh gian that trc cua ong mach vanh trai (chiem 50% cac trng hp NMCT),
o NMCT xuat hien thanh trc that trai, mom tim va 2/3 trc cua vach lien that.
- Tac nhanh mu cua ong mach vanh trai (20% cac trng hp NMCT), o NMCT thanh
ben that trai.
- Tac ong mach vanh phai (30% cac trng hp NMCT), o NMCT thanh sau that trai va
1/3 sau cua vach lien that.
Bnh l H Tim Mch 126
Hnh 25: V tr o NMCT tng ng vi ong mach vanh b tac nghen.
Hnh anh ai the va vi the cua o NMCT thay oi tuy vao thi iem quan sat sau khi xay ra
NMCT:
- Trong 12 gi
au tien, khong the
phan biet c gia o
NMCT vi vung c tim
bnh thng tren ca
ai the lan vi the.
- T 12-24 gi, o
NMCT co mau lt hn
c tim bnh thng;
tren vi the co hien
tng hoai t ong,
cac te bao c tim co
bao tng tr thanh
ong nhat ai toan,
nhan ong, nhan v
hoac nhan tan. (Hnh
26)
Hnh 26: O NMCT t 12-24 gi, te bao c tim co bao tng ong nhat ai toan,
nhan ong, nhan v hoac nhan tan (*).
Bnh l H Tim Mch 127
- T 24-72 gi, o NMCT, co mau vang lt, b ro mau o do hien tng sung huyet cua
vung c tim lan can. Tren vi the, co hien tng phu viem va tham nhap bach cau a nhan vao
gia cac te bao c tim hoai t. (Hnh 27)
Hnh 27: O NMCT t 24 - 72 gi, co mau vang lt, b ro (A, mui ten); Tren vi the, co hien tng phu viem
va tham nhap bach cau a nhan vao gia cac te bao c tim hoai t (B).
- T 3-10 ngay, o NMCT tr nen mem va lom xuong. Tren vi the co hien tng phan ra
va tieu huy cac te bao c tim hoai t nh hoat ong cua cac ai thc bao (hien tng d tieu);
tai b o nhoi mau, qua trnh sa cha hoa seo bat au vi s tang sinh mo lien ket mach mau
tao thanh mo hat. (Hnh 28A)
T ngay 10 tr i: qua trnh hoa seo tien dan ve pha trung tam o NMCT va hoan tat vao
tuan le th 7, o NMCT bien thanh 1 seo x mau trang. (Hnh 28 B, C)
Hnh 28: O NMCT t ngay 3 - 10, te bao c tim hoai t b phan ra va tieu huy (A); hoa seo sau vai tuan (B);
tr thanh seo x mau trang (C)
4. Hau qua va bien chng cua NMCT

NMCT co the gay t vong tc khac do suy tim cap, khi the tch that trai b hoai t hn 40%
hoac khi co roi loan dan truyen nang nh rung that. Neu benh nhan con song sot, van con nguy
c b t vong sau o do cac bien chng sm va muon.
Bnh l H Tim Mch 128
a/ Cac bien chng sm: xay ra trong hai tuan au.
- Tiep tuc b cac t loan nhp tim nang do roi loan dan truyen nh rung that hoac loan
nhp tim cham.
- Suy tim trai do NMCT dien rong, tam that trai b gian ra do o NMCT hoa mem trong phan
ng viem va sa cha.
- V o NMCT, thng xay ra trong khoang thi gian t ngay 3-10, gay ra tran mau mang
tim. S tang ap lc ot ngot trong bao tim se gay chen ep tim lam benh nhan t vong nhanh
chong (Hnh 29). Trong mot so t trng hp, v o NMCT nam tren vach lien that se lam thung
vach nay, tao ra mot shunt t trai qua phai; co the dan en suy tim trai neu shunt qua ln.
Hnh 29: O NMCT b v thung (A), gay tran mau mang tim (B).
- H van 2 la neu o NMCT nam gan c cot tim.

- Huyet khoi vach tim c thanh lap do noi tam mac phu tren o NMCT cung b ton
thng. Huyet khoi nay co the v ra tao thanh cuc huyet tac, gay nhoi mau cac c quan khac
nh nao, lach, than, ruot, chi di. (Hnh 30)
- Viem ngoai tam mac phu ngoai o nhoi mau.
Hnh 30: NMCT lam t c cot tim gay h van 2 la (A), tao huyet khoi vach tim
b/ Cac bien chng muon:

- Suy tim trai man tnh khong ap ng vi ieu tr,
thng gap khi NMCT co dien rong.
- Phnh vach that do o NMCT cu a hoa seo, b
gian ra di tac ong cua ap lc cao trong tam
that (Hnh 31).
- Huyet tac do bong v huyet khoi vach that.
Hnh 31: Phnh vach that do mo seo NMCT b gian

Bnh l H Tim Mch 129
II. VIEM C TIM (myocarditis):
La tnh trang viem lan toa c tim. a so co dien tien lanh tnh nhng 1 so trng hp co
the dan en t vong do suy tim cap hoac loan nhp tim.
Phan biet 3 loai viem c tim:
- Viem c tim do nhiem khuan: tac nhan gay nhiem khuan co the la vi khuan, virut, nam,
ky sinh trung.
- Viem c tim khong do nhiem khuan: th du nh viem c tim do cac benh t mien, do
phan ng thuoc (penicillin, mot so thuoc tr ung th, sulfamid, v.v.), hoac do cac tac nhan vat ly
(tia phong xa).
- Viem c tim cha ro nguyen nhan
Trong ca 3 loai tren, viem c tim do virut la loai thng gap nhat.
Hnh thai ton thng :

- ai the: tim gian to, mem nhao, nhat mau, co cac om xuat huyet rai rac.
- Vi the: trong lp c tim co cac am te bao c tim hoai t, tham nhap cac te bao viem
cap hoac man tuy theo nguyen nhan gay benh. (Hnh 32)
Hnh 32: Viem c tim do virut, tim gian to, mem nhao, co huyet khoi vach tim (A), te bao c
tim hoai t, tham nhap limpho bao va ai thc bao
III. BENH C TIM (cardiomyopathies)

La mot nhom benh ly tac ong chu yeu len
c tim, gay roi loan hoat ong co bop cua tim va
co the dan en suy tim. Tren thc te lam sang,
ch c ngh en benh c tim sau khi a loai tr
tat ca cac nguyen nhan gay suy tim khac thng
gap nh benh van tim, thap tim, benh tim cao
huyet ap, nhoi mau c tim, v.v.
Benh c tim c phan thanh 2 loai:
- Benh c tim nguyen phat, khong ro
nguyen nhan, con goi la benh c tim vo can
(idiopathic cardiomyopathies). (hnh 33)
- Benh c tim th phat, xay ra trong nhieu
benh ly khac nhau nh tieu ng, benh tuyen
giap, benh chat amyloid, viem c tim, ngo oc
ru man tnh.
Hnh 33: Benh c tim nguyen phat
Bnh l H Tim Mch 130
BENH C TIM NGUYEN PHAT c chia thanh 3 loai sau:
- Benh c tim ph ai (hypertrophic cardiomyopathy): vach tim ph ai day len qua mc,
nhat la vach tam that trai va vach lien that; ket qua gay chen ep cac buong tim, lam giam s
o mau vao that trai trong th tam trng va can tr luong thoat mau ra khoi that trai trong th
tam thu, dan en giam cung lng tim. Ve mat vi the, te bao c tim ph ai mot cach bat thng,
xep thanh cac bo phan bo lon xon va co hien tng hoa si mo ke. Benh nhan thng t vong
ot ngot v suy tim, loan nhp tim (rung nh, rung that), huyet khoi va huyet tac. (Hnh 34)
Hnh 34: Vach lien that ph ai chen vao buong tim (A), te bao c tim ph ai, phan bo lon xon (B)
- Benh c tim gian (dilated cardiomyopathy): tim to gap 2-3 lan bnh thng, mem nhao,
sc co bop giam hn 50% so vi bnh thng, lam cung lng tim giam. Cac buong tim gian
rong, vach tim mong va thng co huyet khoi vach tim. Ve mat vi the, cac te bao c tim mot so
ph ai, mot so b teo mong va cung co hien tng hoa si mo ke. Benh nhan t vong do suy
tim tien trien hoac loan nhp tim. (Hnh 35)
Hnh 35: Buong tim gian rong, co huyet khoi vach tim (mui ten) (A); te bao c tim mot so ph ai, mot so b
teo mong i kem vi hien tng hoa si mo ke (B)
- Benh c tim gii han (restrictive cardiomyopathy): tim khong to hoac to t, cac buong
tim khong gian, nhng do lp c tim qua cng chac nen s o mau vao tam that trai trong th
tam trng b gii han, lam giam cung lng tim. Ve mat vi the, co hien tng hoa si mo ke
tng o hoac lan toa trong vach tim. (Hnh 36)
Bnh l H Tim Mch 131
Hnh 36: Tam that khong to nhng cng chac, can tr mau thoat nen lam tam nh gian rong (A), vi the co
hien tng hoa si mo ke lan toa (B)
IV. VIEM NOI TAM MAC NHIEM KHUAN (bacterial endocarditis)

La tnh trang lp noi tam mac b viem do co vi khuan xam nhap va sinh san trong o,
thng thay vung cac van tim. t khi gap viem noi tam mac nhiem khuan do virut, ky sinh
trung hay nam.
Trc thi ai khang sinh, viem noi tam mac la 1 benh bat tr, t vong chac chan; v vay
vao thi o, benh c phan biet thanh 2 loai da theo ac iem lam sang va khoang thi gian
song sot cua benh nhan.
- Viem noi tam mac nhiem khuan cap: do cac vi khuan co oc lc cao nh
staphylococcus aureus, beta streptococcus; thng gay thung van tim, benh nhan t vong trc
6 tuan le.
- Viem noi tam mac nhiem khuan ban cap: do vi khuan t oc hn nh alpha
streptococcus, t gay thung van tim, benh nhan song lau hn, co the en 6 thang.
Ngay nay, s xuat hien cua cac khang sinh a lam thay oi dien tien lam sang va tien
lng benh, ty le t vong c ha xuong con 30 - 50%; viem noi tam mac khong con c phan
biet thanh 2 loai cap va ban cap na, ma la theo loai vi khuan gay benh va loai van tim b ton
thng.
Cac yeu to thuan li lam de b viem noi tam mac nhiem khuan bao gom cac tnh trang
co san ton thng noi tam mac do benh tim bam sinh, thap tim, dung van tim nhan tao, thc
hien thu thuat thong tim, chch x ke ma tuy, v.v.
Hnh thai ton thng:
Ton thng xuat hien chu yeu van 2 la va van ong mach chu. Tren be mat va mep
t do cua la van xuat hien cac not sui nh bong cai, co mau o nau, de v, kch thc t vai
mm en vai cm. Tren vi the, cac not sui cau tao bi fibrin, bach cau, tieu cau tng t nh cau
tao cua cuc huyet khoi nhng co cha nhieu vi khuan,. La van ben di not sui b phu, ngam te
bao viem va co the b hoai t, loet thung. (Hnh 37)
Bien chng:
- H van 2 la: do loet thung la van, t day chang neo van tim
- Huyet tac ong mach: do not sui b v ri vao long mach. Cuc huyet tac nay cha
nhieu vi khuan nen co the gay ra ap xe tai v tr gay tac nghen ma ang s nhat la ap xe nao.
Bnh l H Tim Mch 132
- Bien dang van tim: do qua trnh sa cha hoa seo tiep sau giai oan viem, a en
hep h van tim.
Hnh 37: Not sui nh bong cai tren van 2 la (A), co the gay loet thung la van 2 la (B); not sui tren van ong
mach chu (C); cau tao vi the cua not sui (D).
V. TRAN DCH va TRAN MAU NGOAI TAM MAC

Bnh thng trong khoang mang ngoai tim ch co khoang 5 - 50 ml dch; tran dch ngoai
tam mac xay ra khi co ong dch tren 100 ml; co the gap trong cac benh ly gay phu khong do
viem nh suy tim, suy dinh dng, hoi chng than h. Tran mau ngoai tam mac la tnh trang co
mau trong khoang ngoai tam mac, co the la do v phnh ong mach chu, v o nhoi mau c tim,
chan thng (Hnh 29).
Anh hng cua tran dch hoac tran mau ngoai tam mac len tren hoat ong cua tim tuy
thuoc toc o tran dch/ mau hn la vao so lng dch/ mau ong: vi toc o cham, dch ong
co the len en 1 lt ma van cha co anh hng nhieu; trai lai neu toc o tran dch/ mau nhanh,
ch can 150 - 250 ml cung u gay chen ep tim.
VI. VIEM NGOAI TAM MAC (pericarditis)

Co the xay ra moi la tuoi, nguyen nhan rat a dang: nhiem khuan (vi khuan, virut,
v.v.), cac benh ly mien dch, roi loan chuyen hoa (ure mau cao), chan thng, tia xa.
Hnh thai ton thng:
Ngoai tam mac khong con nhan bong, tr nen san sui neu co lang ong nhieu fibrin, co
the co ong dch xuat trong khoang mang ngoai tim. Tuy theo tnh chat dch xuat, phan biet 4
loai viem ngoai tam mac sau:
- Viem ngoai tam mac thanh huyet.
- Viem ngoai tam mac t huyet.
- Viem ngoai tam mac xuat huyet.
- Viem ngoai tam mac mu.
Bnh l H Tim Mch 133
Trong 3 loai sau, thng co phan ng tang sinh mo si lam day dnh 2 la ngoai tam
mac, co the gay can tr hoat ong co bop cua tim (goi la viem ngoai tam mac co that) (Hnh
38).
Hnh 38: Viem ngoai tam mac t huyet xuat huyet (A), viem ngoai tam mac co that (B)
VII. BENH THAP TIM (rheumatic heart disease)

Bao gom ton thng viem tim trong giai oan sot thap cap tnh va cac di chng bien
dang van tim man tnh.
1. Viem tim (carditis)

Sot thap cap tnh (acute rheumatic fever) la 1 benh viem cap tnh, thng hay tai phat,
xay ra chu yeu tre em 5-15 tuoi. Sot thap cap tnh thng xuat hien khoang 2-3 tuan sau 1
viem hong do beta streptococcus tieu huyet nhom A (xay ra 3% so tre b viem hong). Tre b
sot, co cac bieu hien ton thng tim, khp, da va than kinh; tuy nhien ch ton thng cua tim
la nang nhat va co the e lai di chng bien dang van tim man tnh. Tat ca 3 lp cua tim eu co
the b viem:
- Viem c tim: trong c tim co hien tng tham nhap cac limpho bao va ai thc bao,
ac biet co s xuat hien ton thng ac trng cua benh thap tim goi la the Aschoff, nam trong
mo lien ket xung quanh cac mach mau. Cau tao cua the Aschoff giong nh 1 o viem hat gom 1
trung tam hoai t dang fibrin, bao quanh bi cac limpho bao, tng bao, va 1 loai ai thc bao
ac biet goi te bao Anitschkow, co nhan cha 1 bang chat nhiem sac chnh gia, cac te bao
Anitschkow co the hoa nhap thanh cac ai bao nhieu nhan. The Aschoff cung co the c tm
thay trong lp noi tam mac va ngoai tam mac. (Hnh 39)
Hnh 39: The Aschoff trong c tim, trong o nho la 2 te bao Anitschkow
vi nhan cha bang chat nhiem sac gia.
Bnh l H Tim Mch 134
- Viem ngoai tam mac t huyet: co s lang ong fibrin mat trong cua ca 2 la ngoai
tam mac.
- Viem noi tam mac: chu yeu vung van 2 la va van ong mach chu, co the tao ra cac
not sui tren mep van. Not sui c hnh thanh do s ket tu fibrin tren cac vet loet cua noi tam
mac.
C che gay ton thng tim trong sot thap cap co the do streptococcus co cha cac
khang nguyen tng t vi 1 so thanh phan cau tao cua van tim (th du gia protein M cua vi
khuan vi glycoprotein cua tim); v vay khi c the co ap ng mien dch chong lai streptococcus
th cung gay ra ton thng cho van tim.
2. Di chng bien dang van tim man tnh:

La hau qua qua trnh hoa seo va co keo cua cac ton thng van tim a xay ra trong giai
oan sot thap cap tnh. Cac van tim b hoa si day len, dnh vao nhau dan en hep h van tim.
Di chng bien dang van tim xay ra chu yeu van 2 la va van ong mach chu, t gap van 3 la
va van ong mach phoi. (Hnh 40)
Hnh 40: Cac la van cua van 2 la day len, dnh cac day chang neo van (A), di chng hep van 2 la (B).
VIII. U CUA TIM

U nguyen phat cua tim rat hiem gap, thng lanh tnh. Gan phan na u nguyen phat cua
tim la u nhay, thng xuat hien trong nh trai, kch thc t 1 en 10 cm, co hoac khong co
cuong, cau tao gom nhieu thuy, mat o mem, bong. Ve mat vi the, u c cau tao bi cac te
bao a giac hoac hnh sao, xep rai rac hoac thanh am tren 1 chat nen dang niem. U nhay co
the gay can tr hoat ong cua van 2 la hoac v bong ra thanh cac cuc huyet tac. (Hnh 41)
Hnh 41: U nhay trong tam nh trai (A), hnh anh vi the cua u nhay (B).
U th phat cua tim thng gap hn so vi u nguyen phat, do di can cua cac ung th
phoi, ung th vu, u hac to ac, limphom, v.v.
Bnh l H Tim Mch 135
1. Benh x va ong mach:

A/ Thuoc nhom benh x cng ong mach
B/ Xay ra ong mach c ln va trung bnh
C/ Ton thng la mang x va nam trong lp ao gia thanh mach
D/ Ch A va B ung
E/ Ca A, B, C ung
2. Cuc huyet tac cholesterol co the c hnh thanh khi mang x va :

A/ B loet, nt v be mat B/ B xuat huyet C/ B Calci hoa
D/ Gay nghen mach E/ Lam v mach
3. KHONG PHAI la yeu to nguy c chnh gay mac benh x va:

A/ Tang cholesterol mau B/ Uong ru C/ Nghien hut thuoc la
D/ Benh tieu ng E/ Cao huyet ap
4. Benh Buerger:
A/ La 1 benh viem tnh mach B/ Co lien quan vi hut thuoc la
C/ Co the gay hoai t cac au chi D/ Ca A,B, C ung
E/ Ch B, C ung
5. Hau qua cua benh trng n tnh mach chi di:

A/ Sung huyet tnh B/ Sung huyet ong C/ Roi loan dinh dng da
D/ Ch A va C ung E/ Ch B va C ung
6. Nhoi mau c tim co the gay t vong tc khac do:

A/ Suy tim cap B/ Hoai t > 40% the tch that phai C/ Rung that
7. Bien chng v o nhoi mau thng xay ra:

A/ Trong 12 gi au tien B/ T 12-24 gi C/ T 24-72 gi
D/ T ngay 3-10 E/ T ngay 10 tr i
8. O nhoi mau c tim thng thay nhieu nhat :

A/ Thanh trc that trai B/ Thanh trc that phai C/ Thanh ben that trai
D/ Thanh sau that trai E/ Thanh sau that phai
9. Trong viem noi tam mac nhiem khuan, ton thng xuat hien chu yeu :
A/ Van 2 la B/ Van 3 la C/ Van ong mach chu
D/ Ch A, B ung E/ Ch A, C ung
10. Mot tre trai 5 tuoi b viem tim vi s xuat hien cua the Aschoff va te bao Anitschkow, bien
chng nao co kha nang gap nhieu nhat benh nhi nay 20 nam sau:
A/ Hep van ong mach phoi B/ Hep van 2 la C/ Hep van 3 la
D/ Phnh vach that E/ Day dnh mang ngoai tim
11. Loai u nguyen phat cua tim thng gap nhat la:
A/ Carcinom B/ U nhay C/ U m
D/ sarcom mach mau E/ Limphom
Bnh l H Tim Mch 136
Benh ly he ho hap 137
BENH HE HO HAP
Muc tieu:
1. Mo ta va phan tch 3 loai nhiem khuan ng ho hap di: phe quan phe viem, viem phoi
thuy va lao phoi.
2. Mo ta va phan tch cac benh bui phoi.
3. Mo ta va phan tch 3 loai benh phoi tac nghen man tnh: viem phe quan man tnh, hen
phe quan va kh phe thung.
4. Neu ac iem dch te, lam sang va giai phau benh cua ung th phoi.
He thong ho hap gom 2 la phoi, c noi vi ben ngoai bang mot he thong ong, co chc
nang chnh la lay kh oxy vao va thai loai kh carbonic ra khoi c the.
Hoat ong ho hap bnh thng am bao duy tr ap lc rieng phan cua oxy trong mau PaO2
la 80-100 mmHg va cua kh carbonic PaCO2 la 35-45 mmHg. Khi PaO2 giam di 60 mmHg
hoac PaCO2 ln hn 50mmHg, ta co tnh trang suy ho hap (SHH). SHH co the xay ra do nhieu
loai benh ly khac nhau tai phoi va ngoai phoi; tuy theo s xuat hien va dien tien nhanh hoac
cham, co the phan biet 2 dang SHH: SHH cap tnh va SHH man tnh. Cac bieu hien lam sang
chnh cua SHH gom co tnh trang kho th, tm tai, bt rt, co the dan en gay truy tim mach, l
m, hon me va t vong. Trong suy ho hap, thng co tang ap lc ong mach phoi, dan en ph
ai that phai va/hoac suy tim phai, con goi la benh tam phe (cor pulmonale).
Ve mat benh ly, he thong ho hap c chia thanh 2 thanh phan:
- ng ho hap tren: t lo mui en thanh quan; thng co nhieu vi khuan thng tru nh
Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae va mot so loai vi
khuan k kh.
- ng ho hap di: t kh quan tr xuong, bnh thng khong co vi trung. Cac vi trung
thng tru ng ho hap tren khong lot xuong c la nh vao hoat ong cua cac c che bao
ve t nhien ng ho hap (phan xa ong nap thanh mon, phan xa ho, hoat ong cua he
thong chat nhay - long chuyen va cac ai thc bao...).
BENH LY NG HO HAP DI
I. CAC NHIEM KHUAN HO HAP:
De xay ra khi co s suy yeu cac c che bao ve t nhien ng ho hap.
A. VIEM PHE QUAN CAP (acute bronchitis):
Xay ra moi la tuoi; dien tien benh thng nhe
nhang nhng cung co khi rat nang ne (nhat la cac tre suy
dinh dng). Trieu chng gom sot, ho va khac m, cam giac
nang ngc, co the co kho th va tm tai neu benh nang. Benh
thng khoi han, khong e lai di chng neu c ieu tr kp
thi.
Nguyen nhan thng gap nhat la do virus (virus cum,
adenovirus, respiratory syncytial virus, virus si...). Viem phe
quan cap cung co the do vi khuan (H.influenzae,
Pneumococcus) hoac do nam (th du do Candida albicans,
thng xay ra ngi b suy giam mien dch); viem phe quan
cap do vi khuan se chuyen thanh viem phoi neu khong c
ieu tr kp thi.
Hnh thai ton thng:
Niem mac phe quan b phu ne sung huyet co mau o
Hnh 1: Niem mac phe quan phu
rc, be mat co nhieu m mu. Tren vi the, co cac ac iem
ne, sung huyet, nhieu m mu.
cua hien tng viem cap.(Hnh 1)
B. VIEM PHOI (pneumonia):
La tnh trang viem nhiem ng ho hap di, chu yeu cac phe nang. Da theo hnh thai
ton thng giai phau benh ly, phan biet 2 loai viem phoi sau:
1. PHE QUAN - PHE VIEM (bronchopneumonia):
Thng xay ra tre em, ngi gia hoac cac benh nhan ang mac cac benh nang nh
ung th, suy tim, suy than man hoac tai bien mach mau nao. Benh nhan b sot cao, n lanh, ho,
khac m, au ngc (neu co viem mang phoi). Khi nghe phoi, co ran no rai rac 2 phe trng,
nhieu nhat 2 ay phoi, tng ng vi cac am ong ac.
Tac nhan gay benh thng la cac vi khuan nh Staphylococcus, Streptococcus,
H.influenzae, P.aeruginosa, cac vi khuan ng ruot... Cac vi khuan nay khi au gay ra viem
cac phe quan, sau o lan xuong phe nang. Cac phe nang ay dch phu viem, hnh thanh cac
am ong ac.
Hnh thai ton thng:
Cac am nhu mo phoi b ong ac, ng knh 3- 4 cm, co mau xam hoac o am, mat
o chac, nam rai rac trong cac thuy phoi xen ke vi cac vung phoi lanh. Ton thng thng co
ca 2 phoi va tap trung nhieu ay phoi, phan anh s lang ong theo trong lc cua dch phu
viem vao thuy di. Ve vi the, vung ong ac la cac phe quan, tieu phe quan va phe nang b
viem cap, ay dch xuat mu.(Hnh 2)
Hnh 2: Cac am ong ac rai rac (A), phe nang ay dch xuat mu (B)
Bien chng thng gap trong phe quan - phe viem la ap-xe phoi, viem mang phoi, tran
mu mang phoi, nhiem khuan huyet.
2. VIEM PHOI THUY (lobar pneumonia):
La tnh trang viem toan bo mot thuy phoi
90-95% trng hp la do phe cau trung (Streptococcus pneumoniae) gay ra; viem phoi
thuy do phe cau trung xay ra chu yeu o tuoi t 20-50, t thay tre em va ngi gia. Viem
phoi thuy (VPT) do phe cau trung (PCT) thng khi phat ot ngot vi sot cao, n lanh, ho,
khac m mu co lan vai vet mau (m mau r set). Neu mang phoi cung b viem, co trieu chng
au ngc khi ht vao sau.
Mot vai trng hp viem phoi thuy la do Klebsiella, Staphylococcus, Streptococcus,
H.influenzae; thng xay ra ngi ln tuoi, ngi mac benh tieu ng hoac nghien ru.
C che benh sinh:
Viem phoi thuy (VPT) do phe cau trung (PCT) de xay ra khi cac c che bao ve t nhien
ng ho hap b suy yeu. Th du 1 ngi b nhiem trung ng ho hap tren do virus, s tang
tiet dch trong long phe quan tao ra mot moi trng tot cho s sinh san cua cac PCT.
PCT c boc ngoai bang mot bao nhay co kha nang chong lai hoat ong thc bao cua
cac ai thc bao phe nang, nh vay co the lan tran manh. ai thc bao ch an c PCT sau
khi chung a c opsonin hoa bang cac khang the hoac bo the. (Hnh 3)
Hnh thai ton thng:
Hnh 3: Cac giai oan cua viem phoi thuy
Cac ac iem ai the va vi the cua viem phoi thuy la mot th du ien hnh ve phan ng
viem mu-t huyet cap tnh, dien tien t nhien cua benh gom 4 giai oan. (Hnh 3 va 4)
* Giai oan sung huyet (congestion): keo dai khoang 24 gi, long phe nang ay dch
xuat giau protein, cac tnh mach sung huyet, lam phoi b phu ne va nang hn bnh thng.
* Giai oan gan hoa o (red hepatization): keo dai vai ngay. Long phe nang tham nhap rat
nhieu bach cau a nhan trung tnh va ai thc bao. Nhieu hong cau cung thoat ra t cac mao
mach vao trong long phe nang. Mang phoi tren mat thuy phoi b viem c phu dch xuat t
huyet giau fibrin. Phoi co mau o, do khong con cha khong kh nen tr thanh ac cng tng
t mo gan ti.
* Giai oan gan hoa xam (gray hepatization): keo dai vai ngay. Fibrin lang ong nhieu hn
trong long phe nang, nhieu ai thc bao xuat hien phan huy cac bach cau va hong cau, hien
tng sung huyet giam bt. Phoi co mau xam nau va cng.
* Giai oan hoi phuc (resolution): xay ra vao ngay th 8-10; dch xuat c tai hap thu,
xac te bao c phan huy, cau truc phe nang c phuc hoi nguyen ven va phoi tr lai bnh
thng.
Hnh 4: Viem phoi thuy di phai: giai oan gan hoa o (A); giai oan gan hoa xam (B); vi the giai oan
gan hoa o, phe nang cha ay bach cau a nhan, tng phan vi phe nang cua thuy ben canh (C);
trong giai oan hoi phuc, long phe nang cha nhieu ai thc bao (D).
Bien chng:
Thng xay ra nhng benh nhan co sc e khang yeu; gom co viem mang phoi, tran
dch mang phoi, tran mu mang phoi, nhiem khuan huyet, ap xe phoi, x phoi.
C. LAO PHOI (pulmonary tuberculosis):
Do vi khuan Mycobacterium tuberculosis gay ra. Mac du a co cac thuoc khang lao hieu
qua va thuoc chung nga BCG, lao phoi van con la mot trong nhng nguyen nhan chnh gay t
vong cac nc ngheo. ang s hn na la hien nay a xuat hien nhieu chung vi khuan lao
khang thuoc trong tnh hnh dch benh AIDS ang lan tran, viec ieu tr cang them kho khan va
phc tap. c tnh moi nam tren the gii co them 8-10 trieu trng hp lao phoi (LP) mi va 3
trieu ngi chet v benh lao.
ac iem lam sang - giai phau benh cua benh lao phoi:
Rat a dang tuy theo benh nhan b nhiem khuan lan au hoac tai nhiem, oc lc vi khuan
va sc e khang cua benh nhan. Trieu chng benh co the m ho nh sut can, ho keo dai, ra
mo hoi em hoac ram ro nh sot, kho th, suy ho hap cap. Phan biet 3 loai LP sau (Hnh 5):
Hnh 5: LP nguyen phat, phc hp Ghon (A); LP th phat thuy tren (B); Lao hang (C); Lao ke (D).
1. Lao phoi nguyen phat

La dang LP xay ra ngi mi tiep xuc lan au vi vi khuan lao. Ton thng cua lao
nguyen phat c goi la phc hp Ghon, xuat hien trong vong 2-4 tuan sau khi vi khuan lao
xam nhap vao phoi. Phc hp Ghon gom co 2 thanh phan:
- Mot ton thng viem lao cua nhu mo phoi, ng knh khoang 1cm; v tr ton thng
thng ngay di mang phoi, tren hoac di ranh lien thuy phan cach gia thuy tren va
thuy di.
- Hach bach huyet dan lu vung nhu phoi tren, b sng to do viem lao.
Ve vi the, co s hnh thanh cac nang lao trong ca hai ton thng noi tren. (Hnh 6).
Hnh 6: Cac nang lao vi ai bao Langhans (A); Vi khuan lao bat mau o vi pham nhuom Ziehl-Nielson.
Hau het cac ton thng LP nguyen phat se hoa thanh seo x ong voi va khong e lai
di chng. Trong khoang 5-10% trng hp, co s phat tan vi khuan lao en ni khac trong phoi
hoac trong c the nhng khong bieu hien trieu chng. Ch mot so rat t trng hp (tre nho suy
dinh dng hoac ngi ln b suy giam mien dch), LP nguyen phat co the tien trien va lan rong
thanh cac dang LP tien trien.
2. Lao phoi th phat
Hau het cac LP th phat la ket qua cua s tai hoat hoa mot LP nguyen phat, mot so
trng hp la do tai nhiem vi khuan lao . Ton thng LP th phat luon nam tai nh phoi, oi khi
ca hai ben phoi, ng knh khoang 3 cm vao luc c phat hien tren lam sang. Cac hach ron
phoi thng sng to do viem lao. Ve vi the, co s hnh thanh cac nang lao trong cac ton thng
cua nhu mo phoi va hach bach huyet. Vung nhu mo phoi viem lao thng b hoai t ba au
gia, nhng khong hoa hang do cha co thong thng vi phe quan.
Tuy theo moi can bang gia kha nang mien dch cua benh nhan va oc lc cua vi khuan;
LP th phat co the bien thanh mot seo x ong voi hoac tiep tuc tien trien lan rong thanh cac
dang LP tien trien.
3. Lao phoi tien trien

La mot so trng hp LP nguyen phat hoac th phat ma ton thng tiep tuc lan rong
trong nhu mo phoi hoac en cac c quan khac ngoai phoi. Co the phan biet 3 dang LP tien trien
sau:
a/ Lao hang (cavitary fibrocaseous tuberculosis): la tnh trang cac nang lao ba au phat
trien ln dan va gam vao phe quan, ket qua chat hoai t ba au c dan lu ra ngoai, hnh
thanh hang lao. Hang lao thng thay nh phoi; vach hang tao bi mo si, c lot ben trong
bi mot lp chat ba au mau vang xam. ang chu y la s gia tang ap lc oxy trong hang lao lai
la mot yeu to thuan li cho s sinh san cua vi khuan lao; vi khuan sau o se mn ng ho
hap e lan en cac vung khac trong phoi va mang phoi.
b/ Lao ke (miliary tuberculosis): la tnh trang vi khuan lao t mot ton thng LP nguyen
phat hoac th phat, mn ng bach huyet va ng mau e phat tan, gay ra viem lao lan
rong trong toan bo nhu mo phoi hoac cac c quan khac ngoai phoi nh tuy xng, gan, lach,
than, mang nao. Lao ke thng xay ra ngi co sc e khang qua kem, co the gay t vong
nhanh chong v vay c xem nh mot cap cu noi khoa.
Hnh thai ton thng: nhu mo phoi cha ay cac hat ke mau vang nhat, ng knh vai
mm, tng ng vi cac u hat lao tren vi the.
c/ Phe quan - phe viem lao (tuberculous bronchopneumonia): ngi co sc e khang
kem, vi khuan lao t mot ton thng LP nguyen phat hoac th phat co the lan nhanh theo cac
ng ho hap en cac vung khac trong phoi, gay ra mot tnh trang viem nhu mo phoi theo kieu
cap tnh goi la phe quan - phe viem lao. Ve hnh thai ton thng, khong thay phan ng viem hat
ien hnh, nhng trong dch phu viem th co rat nhieu vi khuan lao, lam tang cao kha nang lay
truyen benh.
II. GIAN PHE QUAN (bronchiectasis):

La tnh trang phnh gian khong hoi phuc cac phe quan va tieu phe quan. Benh nhan co
trieu chng ho keo dai va khac ra nhieu m mu rat hoi (hang tram ml moi ngay), de b cac t
nhiem trung ho hap cap tnh vi cac loai vi khuan khac nhau, ke ca loai vi khuan k kh. Trng
hp benh nang va keo dai co the dan en suy ho hap.
C che benh sinh:
Thanh phe quan b suy yeu va phnh gian do 2 yeu to lien quan mat thiet vi nhau:
- S dan lu cac dch tiet phe quan ra ngoai b can tr: do phe quan b tac nghen bi d
vat, nut nhay, cac khoi u; do dch tiet phe quan qua ac (benh x nang tuy) hoac do roi loan
hoat ong cua cac long chuyen (hoi chng Kartagener).
- Cac nhiem khuan ho hap tai i tai lai: do tnh trang ong dch tiet noi tren hoac do
benh nhan co c a de b nhiem khuan (benh giam gamma globulin trong mau).
Phe quan gian ra lam mu lai cang nhieu, nhiem khuan cang nang, thanh phe quan
cang yeu. Ton thng tiep tuc tien trien theo mot vong lan quan.
Hnh thai ton thng (Hnh 7):
- ai the: gian phe quan thng co ca hai phoi va tap trung nhieu thuy di. Phe
quan gian co ng knh ln gap 5-6 lan bnh thng; co hnh ong, hnh thoi hoac hnh tui; trong
long cha ay dch xuat mu va co hien tng x hoa quanh phe quan.
- Vi the: thanh phe quan gian tham nhap nhieu te bao viem man tnh va c thay bang
mo hat viem. Bieu mo phu co cho bong troc hoac chuyen san gai (t bieu mo ho hap chuyen
thanh bieu mo lat tang). Khi benh a dien tien lau ngay, co hien tng hoa si thanh phe quan
va nhu mo phoi quanh phe quan.
Hinh 7: Gian phe quan va x hoa quanh phe quan (mui ten, A); Long phe quan cha ay mu (1), bong troc
bieu mo phu (2), thanh phe quan x hoa, tham nhap te bao viem man tnh (3, B); Bieu mo phu b
chuyen san gai (1, C).
III. XEP PHOI (atelectasis):

La tnh trang nhu mo phoi b xep khong con cha
khong kh (Hnh 8); ay la mot ton thng kha hoi v
nhu mo phoi xep co the phnh tr lai khi nguyen nhan
c giai quyet; tuy nhien xep phoi nang co the lam
giam s oxy hoa mau va tao thuan li cho nhiem khuan
ho hap.
Phan biet 2 loai xep phoi chnh:
- Xep phoi tac nghen: xay ra khi mot phe quan b
tac nghen hoan toan, khong kh trong nhu mo phoi ben
di cho tac nghen c tai hap thu lam phoi xep
xuong va keo lech trung that ve pha ton thng. Phe
quan b tac nghen thng do tang tiet va ket m
nht, v vay hay gap trong benh hen phe quan, gian
phe quan, viem phe quan man tnh va cac tnh trang
Hnh 8: Xep phoi trai.
hau phau; phe quan cung co khi b tac do mot vat la t
ngoai lot vao.
- Xep phoi chen ep: phoi b ep xep do khoang mang phoi cha ay dch, mau, kh
hoac do vom hoanh nang cao (ap xe di c hoanh, tran dch mang bung); lam trung that b ay
lech sang pha phoi lanh.
IV. BENH PHOI KE (diffuse interstitial disease):

La mot nhom benh ly co ac iem chung la tnh trang viem man tnh va lan toa mo ke
phoi, chu yeu mo ke cua vach phe nang, lam mo ke phoi b x hoa tien trien va khong hoi
phuc. Ket cuc phoi b bien thanh mot tap hp cac khoang kh ngan cach nhau bi vach x trong
giong nh 1 to ong nen con goi la phoi to ong. Benh nhan mac benh phoi ke co trieu chng suy
ho hap man nh kho th, tm tai la do phoi cng kem gian n ch khong phai do tac nghen
ng th nh trong benh phoi tac nghen man tnh; phan anh qua s thay doi cac ch so xet
nghiem tham do chc nang ho hap so vi bnh thng nh: TLC , VC , FEV1 bnh thng
hoac giam t le thuan vi VC, t le FEV1/ VC = 0,8 (giong nh ngi bnh thng).
Nguyen nhan: a xac nh c nguyen nhan cua mot so benh phoi ke, mot so khac th
van cha xac nh c.
- Cac benh phoi ke co nguyen nhan c xac nh:
* Cac benh bui phoi (pneumoconiosis): do ht phai cac bui vo c
* Cac benh viem mo phoi qua man (hypersensitivity pneumonitis): do ap ng mien
dch cua c the chong lai cac khang nguyen c ht vao.
* Benh phoi ke do mot so loai thuoc va cac oc chat: thuoc tr ung th, thuoc diet co.
* Benh phoi ke do nhiem mot so loai virut, vi khuan, nam, ky sinh trung.
- Cac benh phoi ke cha ro nguyen nhan: gom nhieu loai trong o ang chu y nhat la
benh x phoi vo can.
Hnh thai ton thng chung:
Bat ke do nguyen nhan g, ton thng au tien cua hau het cac benh phoi ke la viem phe
nang. Cac te bao viem tham nhap (ai thc bao, limpho bao, BCN trung tnh, BCN ai toan)
vao trong vach phe nang va long phe nang lam vach phe nang b phu ne. Cac chat trung gian
hoa hoc c giai phong t te bao viem lam ton thng them cac te bao nhu mo phoi, kch thch
phan ng tao si collagen, ong thi huy ong them cac te bao viem khac en vung ton thng.
Tnh trang viem phe nang c tiep tuc duy tr, vach phe nang day len, phoi b x hoa tien trien,
co keo va bien dang; ket cuoc bien thanh mot cau truc giong hnh to ong, gom cac boc kh ngan
cach nhau bi cac vach x day (Hnh 9).
Hnh 9: Phoi hnh to ong

A. BENH BUI PHOI (pneumoconioses):
La cac benh phoi gay ra bi s ht vao phoi cac loai bui vo c. Co hn 40 loai bui khoang
chat co the gay ton thng phoi; thng gap nhat va quan trong hn ca la cac loai bui than, bui
silic, asbestos; gay ra cac benh bui phoi tng ng la bui phoi than, benh bui phoi silic va benh
bui phoi asbestos.
S phat trien benh bui phoi tuy thuoc 4 yeu to:
- Khoi lng bui ket lai trong phoi: phan anh ham lng bui trong khong kh ht vao va thi
gian lam viec trong moi trng khong kh o.
- Kch thc cua hat bui: cac hat bui co kch thc cang nho th cang nguy hiem. Nhng
hat nho hn 2m co the lot en tan phe nang, cac ai thc bao phe nang se an cac hat nay va
di chuyen ngc len tieu phe quan e c loai ra ngoai bang he thong chat nhay - long
chuyen hoac i vao cac mach bach huyet.
- oc tnh cua hat bui oi vi te bao: co lien quan vi tnh chat ly hoa cua hat bui. Hat
cacbon khong gay oc cho te bao nhng cac hat silic th co the trc tiep giet chet te bao, kch
thch phan ng viem x hoa.
- Tac dung cong hp cua cac chat kch thch khac kem theo, th du khoi thuoc la lam tang
oc tnh cua cac loai bui.
1. BENH BUI PHOI THAN (coal workers pneumoconiosis):
Xay ra nhng cong nhan khai thac mo than.
Hnh thai ton thng, phan biet 2 the (Hnh 10):
- Benh bui phoi than - the n thuan (simple coal workers' pneumoconiosis): ton thng la
cac dat mau en, ng knh 1-2 mm, nam rai rac trong nhu mo phoi va thng tap trung nhieu
thuy tren va phan tren thuy di. Dat cau tao bi cac ai thc bao ay hat cacbon. Dang
ton thng nay rat t anh hng en chc nang phoi; tuy nhien co khoang 10% so benh nhan se
tien trien sang dang benh bui phoi than the bien chng, do bui than ht vao co lan silic hoac
do hut thuoc la.
- Benh bui phoi than - the bien chng (complicated coal workers' pneumoconiosis) ton
thng la cac seo x mau en, ng knh t 2-10cm, cau tao bi si collagen va hat cacbon,
co the gay co keo bien dang nhu mo phoi va mang phoi. Khi a chuyen sang dang ton thng
nay th du benh nhan khong con tiep xuc vi bui than na, tnh trang x hoa mo ke phoi van
tiep tuc tien trien, cuoi cung dan en phoi to ong. Benh nhan co cac trieu chng cua cua suy ho
hap man tnh nh kho th, tm tai...
Hnh 10: ai the va vi the benh bui phoi than the n thuan (A,B), cac dat mau en cha ai thc bao
carbon (mui ten, B); ai the benh bui phoi than the bien chng, tien trien thanh phoi to ong (C).
2. BENH BUI PHOI SILIC (silicosis):
Silic co nhieu trong cat va a, v vay benh nay thng thay nhng cong nhan khai thac
hoac che tac a. Cac hat silic nguy hiem nhat la cac hat co ng knh < 2m, sau khi lot vao
phe nang se c cac ai thc bao phe nang an. Khac vi bui than, bui silic oc vi te bao
(do lien ket hydro va noi tnh ien gia SiOH vi protein va phospholipid mang) se lam chet cac
ai thc bao a "l an phai". ai thc bao chet giai phong ra ngoai cac enzym, cac chat trung
gian hoa hoc va hat silic khong tieu hoa c. Cac chat trung gian hoa hoc giai phong t ai
thc bao nh fibronectin, PDGF, yeu to tang trng I giong insulin (insulin like growth factor I) se
kch thch phan ng tao si collagen. Cac hat silic lai c ai thc bao khac an va tao thanh
mot vong quan; phoi b b x hoa dan dan thanh phoi to ong.
Hnh thai ton thng:
Khi au la cac not x silic (silicotic nodules) trong nhu mo phoi, thng tap trung thuy
tren cua hai la phoi. Not x co ng knh 2-4 mm, cau tao bi cac bo si collagen cuon tron
quanh cac hat silic. Khi co mot lng ln bui silic ket trong phoi, cac not x xuat hien nhieu hn,
hoa nhap vi nhau thanh cac mang x co ng knh > 1 cm, gay co keo bien dang nhu mo
phoi. en luc nay, tnh trang x hoa nhu mo phoi se tiep tuc tien trien cho du benh nhan khong
con tiep xuc vi bui silic, cuoi cung dan en phoi to ong. Tren lam sang benh nhan se co trieu
chng cua suy ho hap man tnh va de b lao phoi hn ngi bnh thng. (Hnh 11)
Hnh 11: Not x silic (A, B); cac hat silic trong not x thay c di anh sang phan cc (mui ten,B);
Mang x gay co keo nhu mo phoi (mui ten,C); vi the cua mang x (D)
3. BENH BUI PHOI ASBESTOS (abestosis):

Asbestos la mot khoang chat dang si, dai 5-100 m, ng knh 0,25-0,5 m, c s
dung trong san xuat cac vat lieu cach nhiet va cach ien. Da theo hnh dang, phan biet 2 loai
si asbestos (Hnh 12):
- Si cong mem: chrysotile. Loai si nay t nguy hiem hn so vi si thang cng.
- Si thang cng: crocidolite, amosite, tremolite, anthophyllite.
Ca 2 loai si sau khi lot vao phe nang va c ai thc bao an eu co kha nang kch thch
ai thc bao san xuat cac chat trung gian hoa hoc kch thch s tao si. Si abestos con co kha
nang gay ra ung th phoi va mang phoi; kha nang sinh ung nay co the do tac ong cua chnh
ban than si asbestos, nhng cung co the do tac ong cua cac chat sinh ung khac a c hap
phu len be mat cua si; bang chng la nguy c ung th phoi benh nhan b benh bui phoi
asbestos tang len 11 lan neu co hut thuoc la.
Hnh thai ton thng:
La tnh trang x hoa mo ke phoi, khi
au vach phe nang va mo ke quanh cac tieu
phe quan ho hap cua thuy di (khac vi benh
bui phoi than va bui phoi silic, ton thng khi
au thuy tren), sau o tien trien lan rong,
gay co keo va bien dang nhu mo phoi, cuoi
cung dan en phoi to ong. Mang phoi cung b
x hoa tao thanh cac mang cng ng knh
vai cm, day 2-3 mm, goi la mang si mang
phoi, thng thay vung mang phoi pha sau
ben va tren vom hoanh.
iem ac trng e chan oan benh bui
phoi asbestos la s hien dien cua cac the
asbestos (asbestos bodies) co dang si - hat
mau nau; cau tao gom mot loi cha cac si
asbestos, c bao quanh bi mot phc hp
gom protein, polysaccharid va ferritin do ai
thc bao cung cap (Hnh 13).
Hnh 12: Hai loai si asbestos
Hnh 13: Hoa si mo ke lam vach phe nang day len (A); The asbestos co dang si hat (B); Mang si mang
phoi (mui ten) vung mang phoi sau ben va tren vom hoanh (C).
B. BENH VIEM MO PHOI QUA MAN (hypersensitivity pneumonitis):

La hau qua cua viec ht vao phoi trong 1 thi gian dai, cac loai bui hu c co cha khang
nguyen ma c the a c man cam t trc.
Hien nay, a xac nh c hn 30 loai khang nguyen trong moi trng co the gay ra
benh viem mo phoi qua man vi nhng ten goi khac nhau tng ng. Th du benh phoi nha
nong do ht bui cha cac bao t nam actinomycetes co trong rm ra; benh phoi ngi nuoi
chim do ht bui trong phan chim hoac long chim; tng t nh vay ta cung co the thay cac
benh viem mo phoi qua man nhng chan vt, che bien si bong vai
Hnh thai ton thng:
Cac bui hu c lot vao phe nang se gay ra viem phe nang, cac te bao viem (limpho bao,
tng bao, ai thc bao va co the co ca ai bao nhieu nhan) tham nhap vao vach phe nang va
co khi ca trong long phe nang, gay phu ne va x hoa vach phe nang. Tnh trang x hoa co the
tiep tuc tien trien thanh phoi to ong neu benh nhan van tiep tuc ht phai loai bui hu c gay
benh, cach duy nhat e tranh khoi ket cuoc ang s nay la phai xac nh c loai bui hu c
gay benh va ngng tiep xuc vi no. (Hnh 14)
Hnh 14: Benh phoi nha nong, thuy tren b x hoa tien trien va bien thanh to ong (A);
Vach phe nang tham nhap te bao viem va ai bao, hoa si day len (B).
C. X PHOI VO CAN (idiopathic pulmonary fibrosis):

La mot loai benh phoi ke cha ro nguyen nhan, co the xay ra moi la tuoi nhng thng
bat au o tuoi 50-60. X phoi vo can la mot benh co tien lng xau, thng gay t vong
trong vong 2 nam ke t khi phat benh. Ghep phoi la hy vong duy nhat e cha khoi benh.
Hnh thai ton thng:
Khi au la tnh trang viem phe nang rai rac trong nhu mo phoi; te bao viem tham nhap
vach phe nang, gay phu ne va x hoa, cac phe bao I b tieu huy va c thay bang cac phe
bao II tang san. Tnh trang x hoa tien trien nang dan, sau cung dan en phoi to ong nh cac
benh phoi ke khac. (Hnh 15)
Hnh 15: Vach phe nang x hoa day len (A); tien trien thanh phoi to ong (B).
V. BENH PHOI TAC NGHEN MAN TNH (chronic obstructive pulmonary diseases):
La mot nhom benh ly ma ac iem chung la co s tac nghen thong kh trong phoi mot
cach man tnh.
S tac nghen thong kh nay do 2 nguyen nhan:
- Long phe quan b thu hep, lam tang khang lc ng th.
- Nhu mo phoi mat kha nang co hoi, lam giam lc ay kh ra ngoai trong th th ra.
Benh phoi tac nghen man tnh (PTNMT) gom 3 loai chnh: Viem phe quan man tnh, hen
phe quan va kh phe thung.
S tac nghen thong kh c phan anh qua s thay oi cac ch so xet nghiem tham do
chc nang ho hap so vi bnh thng nh: TLC , VC , FEV1 , t le FEV1/ VC < 0,6.
A. VIEM PHE QUAN MAN TNH (chronic bronchitis):
Viem phe quan man tnh (VPQMT) c xac nh tren lam sang khi benh nhan co trieu
chng ho khac m moi nam tren 3 thang, trong t nhat 2 nam lien tiep. VPQMT keo dai cong
them cac t nhiem khuan ho hap cap tnh se dan en tnh trang x hoa vach phe quan va hep
long phe quan, lam xuat hien cac trieu chng cua suy ho hap nh kho th, tm tai.
Hut thuoc la la nguyen nhan chu yeu gay ra viem phe quan man tnh (90% benh nhan
VPQMT la nhng ngi nghien thuoc la; ngay ca nhng ngi hut thuoc la thu ong cung co t
le VPQMT gia tang). Khoi thuoc cung la mot nguyen nhan gay ra kh phe thung, do o VPQMT
a tien trien nang thng co them benh nay. T le VPQMT cung gia tang nhng thanh pho b
o nhiem khong kh, cac nha may co kh thai oc hai nh SO2, NO2.
Hnh thai ton thng:
ai the: niem mac phe quan phu ne, sung huyet. Long phe quan cha nhieu chat nhay
mu. Vach phe quan co the day len va x hoa sau nhieu cac t nhiem khuan ho hap cap tnh,
lam hep long phe quan.
Vi the: co 2 ac iem chnh:
- Tang san va ph ai cac tuyen tiet nhay trong lp di niem mac cua thanh phe quan.
- Tang so lng te bao tiet nhay trong bieu mo ho hap (con goi la chuyen san te bao tiet
nhay cua bieu mo ho hap) ong thi vi s giam so lng te bao co long chuyen
Ngoai ra, co the thay hien tng tham nhap te bao viem va x hoa niem mac khi co them
cac t nhiem khuan ho hap cap tnh. (Hnh 16)
Hnh 16: Tang san va ph ai cac tuyen tiet nhay cua lp di niem mac phe quan (A); Chuyen san te bao
tiet nhay cua bieu mo ho hap (mui ten, B).
B. HEN PHE QUAN (bronchial asthma):
La tnh trang co that phe quan tng t, xay ra nhng ngi co tnh trang cac phe quan
qua nhay cam oi vi cac tac nhan kch thch; gay ra nhng cn kho th kch phat. Cn hen phe
quan thng keo dai vai tieng ong ho. Khi het cn, benh nhan ho khac ra nhieu am nht.
Trong mot t trng hp (thng la cac benh nhan a b hen t lau), cn hen phe quan keo dai
nhieu ngay, khong ap ng vi ieu tr va c goi la cn hen ac tnh.
Phan biet 2 loai hen phe quan:
- Hen do d ng: xay ra do ap ng qua mien typ 1 cua c the oi vi cac d ng
nguyen co trong bui, phan hoa, long thu...
- Hen khong do d ng: thng xay ra sau cac viem ng ho hap do virut (rhinovirus,
parainfluenza virus), hoac do thi tiet lanh gia, khong kh o nhiem, hoat ong gang sc, cac
stress tam ly...
C che benh sinh: tng oi c hieu ro trong loai hen phe quan do d ng.
Khi benh nhan ht phai cac d ng nguyen ma c the a c man cam t trc, ap ng
qua man typ 1 se xay ra. Cac d ng nguyen nay gan len cac IgE tren be mat cac masto bao,
co san trong niem mac phe quan. S gan ket nay lam masto bao c hoat hoa va giai phong
ra cac chat trung gian hoa hoc nh histamine, leukotrien, prostaglandin, cytokin va protease co
tac dung:
- Kch thch c trn gay co that phe quan mot cach trc tiep hoac gian tiep qua trung gian
phan xa than kinh pho giao cam (Tk X); lam hep long phe quan.
- Kch thch niem mac phe quan tang tiet nhay, co the tao thanh nut nhay lam bt tac phe
quan.
- Lam gian mach va tang tnh tham thanh mach, gay phu ne niem mac phe quan lam hep
them long phe quan.
- Thu hut va hoat hoa cac bach cau a nhan (trung tnh, ai toan), tieu cau. Cac te bao nay
giai phong cac chat trung gian hoa hoc co tac dung tng t tren, ngoai ra con co the gay ton
thng niem mac phe quan.
Ket qua la long phe quan b thu hep, khang lc ng th tang gay tac nghen thong kh.
(Hnh 17A)
Hnh 17: So sanh gia phe quan bnh thng va hen phe quan (A ; Mot trng hp hen ac tnh t vong do
nut nhay bt hoan toan chac 3 kh phe quan (B).
Hnh thai ton thng:

ai the: phoi cang phong, co the co mot vai vung xep phoi nho do long cac phe quan b
bt tac hoan toan bi nut nhay. (Hnh 17B)
Vi the:
- Niem mac phe quan sung huyet, phu ne va tham nhap cac te bao viem (chu yeu la cac
BCN ai toan); bieu mo co nhng vung b hoai t, bong troc.
- Mang ay di bieu mo day len.
- Ph ai va tang san cac te bao tiet nhay trong bieu mo va cac tuyen nhay trong lp
di niem mac.
- Ph ai va tang san cac te bao c trn trong vach phe quan (hau qua cua tnh trang co
that phe quan keo dai).
- Nut nhay trong long phe quan co cha cac the xoan Curschmann, nhieu BCN ai toan
va cac tinh the Charcot-Leyden. The xoan Curschmann c tao bi cac am bieu mo phe
quan bong troc va xoan vao nhau, tinh the Charcot-Leyden c tao ra bi s ket tu cac protein
cua mang BCN ai toan. (Hnh 18)
Hnh 18: Nut nhay trong long phe quan (A); Vach phe quan tham nhap nhieu bach cau ai toan (1), tang san
te bao tiet nhay trong bieu mo (2), mang ay day len (3), tang san lp c trn (4, B); Chat nhay
trong long phe quan cha nhieu bach cau ai toan va tinh the Charcot-Leyden (C); The xoan
Curschmann t chat khac cua benh nhan hen phe quan (D)
C. KH PHE THUNG (emphysema):

La tnh trang phnh gian vnh vien cac ng dan kh ben
di cac tieu phe quan tan (gom tieu phe quan ho hap, ong
phe nang va cac phe nang) do vach cua chung b pha huy
nhng khong co phan ng hoa si kem theo nh trong benh
phoi ke. Cac vach phe nang b pha huy lam giam dien tch trao
oi kh; nhu mo phoi mat cac si chun nen giam kha nang co
hoi, giam lc ay kh ra ngoai trong th th ra (Hnh 19).
Phan biet 2 loai kh phe thung chnh (hnh 20):
- Kh phe thung trung tam tieu thuy: la loai thng gap
nhat. Phan phnh gian nam trung tam v ch co cac tieu phe
quan ho hap b phnh gian trong khi cac phe nang ngoai vi
tieu thuy van con bnh thng. Tuy nhien, khi benh a tien trien
nang th cac phe nang cung b phnh gian lam kho phan biet Hnh 19: Kh phe thung toan bo
vi loai kh phe thung toan bo tieu thuy. tieu thuy
Kh phe thung trung tam tieu thuy thng xay ra thuy tren phoi, co lien quan chat che vi
tat nghien hut thuoc la va thng co bieu hien lam sang muon sau 50 tuoi.
- Kh phe thung toan bo tieu thuy: toan bo tieu thuy b phnh gian do tat ca cac tieu phe
quan ho hap, ong phe nang va phe nang eu b phnh gian. Kh phe thung toan bo tieu thuy
thng xay ra thuy di, co lien quan vi tnh trang thieu hut 1-antitrypsin va thng co bieu
hien lam sang sm trc 40 tuoi.
Kh phe thung ch co bieu hien lam sang khi t nhat 1/3 nhu mo phoi a b pha huy. Benh
nhan co trieu chng kho th, th nhanh nong, long ngc gian n hnh thung, tien trien t t en
suy ho hap va suy tim phai.
Hnh 20: Hai loai kh phe thung

C che benh sinh:
C che hnh thanh kh phe thung c cho la do s mat can bang gia elastase va cac
protein oi khang elastas.
Trong nhu mo phoi, elastase c san xuat chu yeu bi cac BCN trung tnh va cac ai
thc bao; ay la mot enzym co kha nang phan huy cac si chun trong vach phe nang. oi
khang lai elastase la 1-antitrypsin do gan san xuat, co trong huyet tng va dch ke nhu mo
phoi.
ngi bnh thng, co s can bang gia elastase c san xuat trong phoi vi 1-
antitrypsin. ngi b thieu hut 1-antitrypsin do di truyen (roi loan hoat ong cua gen ma hoa
cho 1-antitrypsin nam tren nhiem sac the 14), s can bang nay b pha v, elastase se pha huy
dan cac vach phe nang, gay ra kh phe thung. ngi nghien thuoc la, nicotin va cac hoa chat
khac co trong khoi thuoc, mot mat co kha nang thu hut nhieu BCN trung tnh va cac ai thuc
bao en phoi giai phong elastase; mat khac lai c che hoat ong cua 1-antitrypsin; ket qua
hoat ong cua elastase troi hn, gay ra kh phe thung.
Nhac lai mo hoc: n v cau truc cua phoi la cac tui phoi (lung acini) ng knh khoang 7mm, cha phan
nhu mo phoi ben di moi tieu phe quan tan, gom co tieu phe quan ho hap, ong phe nang, tui phe nang va
phe nang. Khoang 3 en 5 tui phoi hp lai thanh mot tieu thuy phoi (lung lobule) co ng knh khoang 1- 2
cm. Cac tieu thuy phoi co hnh thap, nh hng ve ron phoi, ay tiep xuc vi mang phoi, ngan cach vi
nhau bang cac vach lien ket mong co cha cac nhanh cua tnh mach phoi va mach bach huyet, ong mach
phoi th phan nhanh theo sat cay phe quan.
Hnh thai ton thng:
ai the: phoi phnh ln che lap ca tim, mau sac lt lat.
Vi the: vach phe nang b pha huy nhng khong co phan ng tao mo si, cac phe nang sat
nhap thanh cac tui kh ln. (Hnh 21)
Hnh 21: Kh phe thung trung tam tieu thuy (A, B), tieu phe quan ho hap (*) b phnh gian trong khi cac phe
nang ngoai vi tieu thuy van con bnh thng; Kh phe thung toan bo tieu thuy (C, D).
VI. U PHOI
Gom 2 loai nguyen phat va th phat.
A. U PHOI NGUYEN PHAT:
Gom cac u lanh va u ac. 95% u phoi nguyen phat la carcinom xuat phat t bieu mo phe
quan, v vay khi noi en ung th phoi la noi ve carcinom phe quan.
1. CARCINOM PHE QUAN (bronchogenic carcinoma):
La loai ung th rat thng gap, xay ra gii nam nhieu hn n. Ket qua ghi nhan ung th
tai Benh vien Ung bu Tp. HCM va Benh vien K Ha noi (2004-2008) cho thay ung th phoi
cung ng hang th 1 gii nam, hang th 3 va 4 gii n. Ung th phoi thng xay ra trong
o tuoi 40-70, t thay trc 40 tuoi. Ung th phoi co tien lng rat xau do tnh chat ac tnh cua
no, t le song them 5 nam ch vao khoang 5-10%. Khi benh c chan oan th ch co khoang
15% trng hp la con mo c.
Nguyen nhan:
Hut thuoc la la nguyen nhan chnh, co moi lien he chat che gia so ieu hut moi ngay,
cach hut va thi gian nghien hut vi nguy c b ung th phoi. Nguy c ung th phoi ngi hut
thuoc cao hn ngi khong hut t 10 -20 lan. Trong hn 1200 chat c tm thay trong khoi
thuoc, co nhieu chat sinh ung nh benzopyrene co the kch thch bieu mo phe quan chuyen san
gai va hnh thanh cac ton thng tien ung nh nghch san. (Hnh 22)
Ngoai ra con co mot so tac nhan khac co the gay ung th phoi a c ghi nhan nh:
asbestos, chrome, nickel, cac chat phong xa, cac seo phoi cu.
Hnh 22: Cac thay oi lan lt co the gap bieu mo phe quan ngi hut thuoc la: Tang san te bao tiet
nhay (A); Tang san te bao ay (B); Chuyen san gai (C); Nghch san nhe, va va nang (D);
Carcinom tai cho (E); sau o chuyen thanh carcinom te bao gai xam nhap (F).
Hnh thai ton thng:

ai the:
Carcinom phe quan thng xuat phat t cac phe quan ln gan ron phoi (phe quan goc,
phe quan cap 2 va 3); ch 1/3 trng hp la xuat phat t cac tieu phe quan va ong phe nang
trong phan ngoai vi phoi. Ton thng ban au co dang mot am san sui go cao tren be mat
niem mac hoac an loet vao niem mac phe quan. Ton thng ln dan, tao thanh mot khoi u lam
bt hep long phe quan, hoac xam nhiem qua vach phe quan vao mo xung quanh phe quan. U co
mau xam trang, mat o cng chac; neu u qua ln, co the co xuat huyet hoai t gia tao thanh
hang.
Carcinom phe quan tien trien se xam nhap vao mang phoi, mang tim, thanh ngc; di can
theo ng mach bach huyet en cac hach bach huyet xung quanh kh-phe quan, hach trung
that va hach tren on. Mot dang ai the khac c goi la viem mach bach huyet do carcinom
(lymphangitis carcinomatosa), la tnh trang cac mach bach huyet di mang phoi noi ro len do
ay cac te bao carcinom phe quan. (Hnh 23)
Carcinom phe quan co the cho di can xa theo ng mau en moi c quan trong c the
nhng thng gap nhat la tuyen thng than, gan ,nao, xng, da.
Hnh 23: Carcinom phe quan co dang choi sui, gay bt hep long phe quan (A); phat trien xam nhap nhu mo
phoi xung quanh va di can vao hach di chac ba phe quan (B); u xuat huyet hoai t tao hang,
xam nhap gay co keo mang phoi (C); tnh trang viem mach bach huyet do carcinom (D).
Vi the:
Carcinom phe quan c phan thanh 4 loai (Hnh 24):
- Carcinom te bao gai: : 25-30 %
- Carcinom tuyen (ke ca carcinom tieu phe quan - phe nang) : 30-35 %
- Carcinom te bao ln : 10-15 %
- Carcinom te bao nho : 20-25 %
Cac dang vi the tren co the phoi hp vi nhau tren cung mot benh nhan ung th phoi.
- Carcinom te bao gai (squamous cell carc.):
La loai ung th co lien he mat thiet vi tat hut
thuoc la. U thng co v tr trung tam, xuat
phat t cac phe quan ln gan ron phoi. U c
tao bi cac am te bao gai co o biet hoa cao,
va hoac kem. Trng hp biet hoa cao, co the
thay cac the lien ket te bao va cac cau sng. So
vi cac loai carcinom phe quan khac th loai nay
co khuynh hng xam nhap manh tai cho nhng
cho di can xa cham hn. (Hnh 24A)
- Carcinom tuyen (adenocarcinoma):
La loai carcinom phe quan thng gap phu
n va nhng ngi khong hut thuoc. U thng
xuat hien vung ngoai vi phoi. Phan biet 2 loai:
* Carcinom tuyen phe quan: ung th xuat phat
t bieu mo tieu phe quan. Tuy mc o biet hoa,
cac te bao ung th co the tao thanh cau truc
tuyen ro ret hoac ch la nhng am ac. Te bao
ung th co the hoat ong san xuat mucin. (Hnh
24B)
* Carcinom tieu phe quan-phe nang (bronchio-
alveolar carc.): ung th xuat phat t cac tieu phe
quan tan hoac phe nang. Cac te bao ung th co
hnh tru cao hoac vuong, nam lot doc vach phe
nang va tao ra cac nhu tho vao long phe nang;
te bao ung th thng bong troc vao long phe
nang tao thanh cac am ac. Te bao ung th co
the hoat ong san xuat chat nhay. (Hnh 24C)
- Carcinom te bao ln (large cell carc.):
La loai ung th co o ac tnh rat cao, sm cho
di can xa. U co v tr trung tam hoac ngoai vi
phoi; cau tao bi cac te bao ln, nhan sang, co
cac te bao khong lo d dang nhieu nhan, phan
bao bat thng. (Hnh 24D)
- Carcinom te bao nho (small cell lung carc.):
La loai carcinom phe quan co lien he vi tat
hut thuoc la. Ung th thng co v tr trung
tam, xuat phat t cac te bao than kinh noi tiet
niem mac phe quan. V vay, u thng co hoat
ong san xuat va a vao trong mau cac
hormon polypeptt, gay ra cac hoi chng can
ung th. U cau tao bi cac te bao nho (kch
thc gap oi lympho bao), nhan hnh tron hoac
bau duc, am, bao tng t, xep thanh tng am
nho. Carcinom te bao nho co o ac tnh rat cao,
lan rong nhanh va sm cho di can xa nen c
xem la loai khong the ieu tr bang phau thuat.
(Hnh 24E)
Hnh 24: Cac dang vi the cua carcinom phe quan.
Carcinom te bao gai (A), Carcinom tuyen phe quan
(B), Carcinom tieu phe quan - phe nang (C),
Carcinom te bao ln (D), Carcinom te bao nho (E)
Lien he lam sang:
Trieu chng lam sang a dang tuy theo v tr cua khoi u va giai oan tien trien cua ung
th. oi vi cac khoi u trung tam, benh nhan thng co ho, khac m lan mau. Khoi u ln lam
hep tac long phe quan co the gay xep phoi, phan phoi xep thng b nhiem khuan lam benh
nhan b sot, au ngc. Cac khoi u ngoai vi phoi cung gay ra cac trieu chng tren nhng muon
hn.
Khi ung th a tien trien xam nhap vao cac c quan lan can hoac di can xa, benh nhan se
co cac trieu chng tng ng, th du:
- Viem va tran dch mang phoi hoac mang tim do ung th xam nhap.
- Liet c hoanh do day than kinh hoanh b xam nhap.
- Khan tieng do day than kinh hoi thanh quan trai b xam nhap.
- Hoi chng tnh mach chu tren (phu mat co va phan tren than) do tnh mach chu tren b
xam nhap chen ep.
- Hoi chng Horner (mat tut nho, sup m, co nho ong t, kho da phan than cung ben) do
mang than kinh giao cam co b xam nhap.
- Hoi chng Pancoast (la hoi chng Horner nhng co them au va teo c canh tay ban
tay) do ung th nam nh phoi, chen ep len mang than kinh tay va mang than kinh giao cam
co.
- Cac trieu chng tam - than kinh do ung th di can nao.
- Cac hoi chng can ung th (paraneoplastic syndrome): la cac phc hp trieu chng xay
ra do cac te bao ung th san xuat ra cac hormon hoac cac chat tng t hormon von khong co
mo nguyen uy; th du nh ADH (lam nc, ha natri mau), ACTH (gay ra hoi chng Cushing),
hormon tuyen can giap (lam tang calci mau), calcitonin (lam ha calci mau), gonadotropin (gay ra
chng n hoa tuyen vu), seretonin (gay ra hoi chng carcinoid gom co cac t tieu chay, o
mat, tm tai)...
Khi ung th phoi a c xac nh, tien hanh xep hang TNM va giai oan lam sang nham
la chon phng thc ieu tr thch hp.
T N M
T1: u < 3cm N0: cha di can hach M0: cha co di can xa
T2: u > 3cm N1: di can hach ron phoi cung ben M1: co di can xa
T3: u a xam nhap vao mang phoi, N2: di can hach trung that cung ben
bao tim, c hoanh nhng con N3: di can hach oi ben
cach chac 3 phe quan 2 cm
T4: u a xam nhap en cac c quan
trong trung that
Phng phap ieu tr bang phau thuat ch cho ket qua tot khi ung th con giai oan T1-
2, N0, M0 hoac T1, N1, M0 va khong phai la loai carcinom te bao nho. oi vi loai carcinom te
bao nho la loai u rat nhay vi hoa tr, thng ch dung phng phap hoa tr phoi hp vi xa tr.
2. Cac loai u phoi nguyen phat khac
Hiem gap, gom cac u si lanh hoac ac, u c trn lanh hoac ac, u m, u mach mau, u sun,
lymphom Hodgkin va lymphom khong Hodgkin, hamartom (tao bi mo sun trng thanh lanh
tnh), u carcinoid phe quan, v.v.
B. U PHOI TH PHAT
Do cac ung th ni khac di can en phoi. Moi loai carcinom va sarcom eu co the di
can en phoi theo ng mau, bach huyet hoac xam nhap trc tiep (th du nh ung th thc
quan, lymphom trong trung that co the xam nhap trc tiep vao phoi). Cac carcinom thng cho
di can phoi la carcinom cua vu, than, ng tieu hoa, buong trng.
Hnh thai ton thng la cac not rai rac trong tat ca cac thuy phoi (hnh anh tha bong
bong tren X-quang, co cau tao vi the tng t u nguyen phat. (Hnh 25)
Hnh 25: Dang ai the nhieu not rai rac trong carcinom di can phoi (A); carcinom tuyen di can theo ng
mau, tao thanh cuc huyet tac ung th (mui ten) gay bt tac mot nhanh ong mach (B).
BENH LY NG HO HAP TREN

ang chu y la cac benh ly sau:
1. Polyp mui: thng xay ra sau nhieu t viem mui do vi khuan hoac d ng, niem mac
mui ph ai nho ra tao thanh mot polyp co kch thc t 3-4cm. Ve mat vi the, polyp mui la mot
ton thng gia u, cau tao bi mot mo em phu ne, tham nhap nhieu te bao viem nh BCN
trung tnh hoac ai toan, tng bao va lympho bao. Be mat polyp c phu bi bieu mo ho hap
bnh thng. (xem hnh 2, benh ly U)
2. Carcinom hau mui (nasopharyngeal carcinoma): con goi ung th vom hau. ay la
loai ung th thng gap chau Phi, Trung hoa va cac nc ong Nam A. Ung th thng tien
trien am tham, khi c phat hien th a xam nhap vao san so hoac di can hach co. Ton thng
ban au la mot am sui trong vung hau mui. Ve mat vi the, carcinom hau mui co 3 dang:
carcinom te bao gai sng hoa, carcinom khong sng hoa va carcinom khong biet hoa. Trong
loai th ba, te bao ung th co kch thc ln, nhieu bao tng, nhan bau duc sang, co hach
nhan to; cac te bao ung th hp thanh tng am, c bao quanh bi nhieu lympho bao hoac
nam xen ke vi cac lympho bao. (xem hnh 16, benh ly U)
Hnh 26: Polyp day thanh (A); carcinom te bao gai thanh quan (B).
3. Polyp thanh quan: thng xay ra ngi nghien thuoc la nang hoac co nghe
nghiep phai s dung day thanh am qua nhieu. Ton thng nam tren day thanh am, co dang cuc
tron, lang, kch thc vai mm, co hoac khong co cuong. Polyp c phu bi bieu mo lat tang
tang san, mo em tao bi mo lien ket tha dang niem, cha nhieu mach mau dan rong. (Hnh
26A)
4. U nhu thanh quan:
ngi ln, u nhu thng n oc, nam tren day thanh am, kch thc <1cm, cau tao
bi cac nhu gom mot truc lien ket mach mau co bieu mo lat tang phu ben ngoai. U nhu nay
khong co tiem nang hoa ac, hiem khi tai phat sau mo cat bo.
oi vi tre em, u nhu thanh quan thng gom nhieu u nam rai rac nen con goi la benh
nhu (papillomatosis); nguyen nhan do nhiem virus HPV (human papillomavirus). U hay tai phat
sau cat bo; nhng trng hp benh keo dai co the dan en ung th.
5. Ung th thanh quan: bieu mo lat tang cua day thanh am co the b nghch san do cac
tac nhan sinh ung (thuoc la, HPV, asbestos) va chuyen thanh carcinom te bao gai. Ton thng
tren ai the la cac am sui loet nam tren day thanh am. Hnh anh vi the la cac am carcinom te
bao gai (Hnh 26B).
BENH LY MANG PHOI
a so cac benh ly cua mang phoi (MP) la bien chng

cua mot benh khac tai phoi hoac ngoai phoi. Ch mot so rat t
trng hp la nguyen phat nh viem mang phoi nguyen phat
(do vi khuan t trong mau i thang vao mang phoi) va ung th
mang phoi nguyen phat.
1. TRAN DCH MANG PHOI VA TRAN KH MANG PHOI
Bnh thng 2 la mang phoi ap sat vao nhau va ch co 1
t dch trong khoang mang phoi (khoang 15ml ) e boi trn be
mat mang phoi. Khi co mot lng dch nhieu hn tu lai hoac
co kh th goi la tran dch mang phoi va tran kh mang phoi
(Hnh 27). Bang sau ay trnh bay tom tat cac loai tran dch,
tran kh va cac nguyen nhan tng ng thng gap:
Hnh 27: Tran mu mang phoi
Ton thng Loai dch Nguyen nhan thng gap
Tran dch MP Dch tham Suy tim, x gan, suy than
Tran mau MP Mau Chan thng, v phnh ong mach chu
Tran mu MP Mu Phe quan - phe viem, Viem phoi
Tran bach huyet MP Dch bach huyet Tac nghen mach bach huyet do u bu
Tran kh MP Kh V phe nang (kh phe thung, hang lao), chan thng
2. VIEM MANG PHOI

Thng gap trong cac benh ly sau:
- Benh he tao keo: sot thap, viem khp dang thap, lupus ban o he thong.
- Nhiem khuan: viem phoi, lao phoi, ap xe phoi.
- Nhoi mau phoi.
- Ung th phoi.
Hau het cac viem mang phoi eu co tran dch mang phoi kem theo. Tuy theo nguyen
nhan, dch lai co the la dch tiet thanh - t huyet, mu hoac mau. Tuy mc o viem, viem mang
phoi co the khoi hoan toan hoac co hoa si gay x hoa mang phoi.
3. UNG TH MANG PHOI NGUYEN PHAT

Con goi la u te bao trung bieu mo ac tnh (malignant mesothelioma), co lien quan chat
che vi benh bui phoi asbestos. Thi gian t luc tiep xuc asbestos en luc phat trien ung th
thng c tnh khoang 30 nam. Benh nhan b au ngc, kho th cang luc cang nang va thng
chet trong vong 2 nam ke t khi c chan oan.
Hnh thai ton thng
ai the: ung th lan rong khap mang phoi, xam nhap vao cac cau truc cua long ngc
(than kinh lien sn, mach bach huyet, hach trung that). Toan bo phoi b bao bi mo u day, mau
xam.
Vi the: u cau tao bi 2 thanh phan tron lan vi nhau. Thanh phan bieu mo gom cac te
bao hnh vuong hoac tru, tao thanh nhu hoac cac ong tuyen; thanh phan trung mo gom cac te
bao hnh thoi trong giong nh sarcom si. (Hnh 28)
Hnh 28: Ung th mang phoi nguyen phat, toan bo phoi b bao bi mo bu (A);
U cau tao bi thanh phan tuyen (1) va thanh phan giong sarcom si (2, B)
1. Ton thng la cac am ong ac, do cac phe quan, tieu phe quan, phe nang b ay mu,
nam rai rac trong cac thuy phoi, xem ke vi cac vung phoi lanh, tap trung nhieu ay phoi, la
hnh anh cua benh :
A/ Viem phe quan cap B/ Phe quan phe viem C/ Viem phoi thuy
D/ Lao ke phoi E/ Gian phe quan
2. Loai vi trung hay gay benh viem phoi thuy nhat la :
A/ Staphylococcus aureus B/ Streptococcus pneumoniae
C/ Streptococcus pyogenes D/ Haemophilus influenzae
E/ Pseudomonas aeruginosa
3. Phc hp Ghon la ton thng ac trng cua :
A/ Phe quan phe viem B/ Viem phoi thuy C/ Lao phoi nguyen phat
D/ Lao phoi th phat E/ Lao phoi tien trien
4. Hut thuoc la la nguyen nhan dan en benh :
A/ Bui phoi than B/ Viem phe quan man C/ Kh phe thung
D/ A va B ung E/ B va C ung
5. Xet nghiem mau m thay co tinh the Charcot - Leyden, xoan Curschmann va bach cau ai
toan, chng to benh nhan co the ang mac benh:
A/ Gian phe quan B/ Hen phe quan C/ Viem phe quan man tnh
D/ Kh phe thung trung tam tieu thuy E/ D vat ng th
6. Trong ung th phe quan nguyen phat, nhan xet nao sau ay la ung :
A/ Phu n thng b loai carcinom te bao gai
B/ Loai carcinom te bao gai thng co v tr ngoai vi
C/ Loai carcinom te bao ln chiem t le cao nhat
D/ Loai carcinom tuyen co t le ngay cang tang cao
E/ Loai carcinom te bao nho co dien tien cham nhat
7. Mot benh nhan nam nghien thuoc la nang a 20 nam, co trieu chng kho th, th nhanh, long
ngc gian n hnh thung, tham do chng nang ho hap co FEV1 , t le FEV1/VC < 0,6. Tnh
trang nay la do cac c che benh sinh sau, NGOAI TR:
A/ Cac BCN trung tnh va ai thc bao c thu hut en phoi
B/ BCN trung tnh va ai thc bao giai phong elastase
C/ Hoat ong cua 1-antitrypsin b c che
D/ ai thc bao san xuat PDGF va TGF beta kch thch tang sinh mo lien ket
D/ Cac si chun trong vach phe nang b phan huy
8. Phoi to ong la ton thng phoi do:
A/ Benh bui phoi B/ Benh viem phoi qua man C/ Dan phe quan
D/ Kh phe thung E/ A va B ung
9. Ton thng viem hat khong c tm thay trong :
A/ Lao phoi nguyen phat B/ Lao phoi th phat C/ Lao hang phoi
D/ Lao ke D/ Phe quan phe viem lao
10. Trong kh phe thung trung tam tieu thuy, thanh phan nao sau ay b phnh dan :
A/ Tieu phe quan tan B/ Tieu phe quan ho hap C/ Ong phe nang
D/ Tui phe nang E/ Phe nang
11. Mot benh nhan nam 65 tuoi co trieu chng au ngc, kho th; chup CT thay toan bo phoi b
bao boc bi mo bu day; sinh thiet mang phoi cho thay u cau tao bi thanh phan tuyen va
thanh phan giong sarcom si. Co kha nang benh nhan b loai u nay do a ht phai:
A/ Si asbestos B/ Bui phan chim / Bui silic
D/ Bui than E/ Bui si bong vai
12. Trong benh bui phoi, ton thng tm thay mo ke phoi, tren vach cac phe nang la:
A/ Tham nhap te bao viem kem tang san mo si
B/ Tham nhap te bao viem kem pha huy si collagen
C/ Tham nhap te bao viem kem tang san si chun
D/ Si chun b pha huy kem tang san mo si
E/ Si chun b pha huy khong kem tang san mo si
13. Be gai 12 tuoi en kham benh v thng b ho, kho khe va len cn kho th, ac biet khi chi
vi cho meo. Be khong sot, phoi cang phong khi len cn kho th, IgE/huyet thanh tang cao. ac
iem vi the nao sau ay la ac trng cho benh ly phoi c mo ta nh tren be gai nay?
A/ Phnh gian cac tieu phe quan ho hap va phe nang
B/ U hat vi ai bao Langhans, te bao dang bieu mo va chat hoai t ba au
C/ Tham nhap te bao viem, x hoa va day vach phe nang
D/ Day mang ay, tang san tuyen tiet nhay, viem niem mac phe quan va ph ai c trn
phe quan
E/ Cac phe quan, tieu phe quan, phe nang ay dch phu va bach cau a nhan trung
tnh
14. Trong cac carcinom phe quan, loai mo hoc nao sau ay xuat phat t te bao than kinh noi tiet:
A/ Carcinom te bao gai B/ Carcinom tuyen phe quan
C/ Carcinom tieu phe quan- phe nang D/ Carcinom te bao ln
E/ Carcinom te bao nho
Benh Ly Ong Tieu Hoa 161
BENH LY ONG TIEU HOA
Muc tieu :
1. Ke ten cac ton thng viem va u khoang mieng va tuyen nc bot
2. Mo ta va phan tch 5 loai ton thng thc quan.
3. Mo ta ton thng cua viem da day cap va man tnh
4. Mo ta va phan tch ton thng loet da day.
5. Ke ten cac loai u da day.
6. Mo ta va phan tch ton thng carcinom da day.
7. Ke ten cac loai ton thng ruot non va ai trang.
8. Mo ta, phan tch, so sanh cac ton thng trong benh viem loet ai trang va benh Crohn.
9. Mo ta cac ton thng u ai trang.
10. Mo ta va phan tch cac ton thng carcinom ai trang.
11. Ke cac ton thng ruot tha.
KHOANG MIENG
I. TON THNG VIEM LOET

A. Viem loet mieng apt (aphthous ulcer):
Dch te hoc: benh thng gap trc 20 tuoi.
Benh sinh: benh khi phat do stress, sot, dung mot loai thc an nao o, b kch hoat bi
benh viem ruot. Nguyen nhan gay benh cha c biet ro. Benh t gii han va lanh sau 7-10
ngay; co the tai phat cho cu hay ni khac.
Hnh thai ton thng:
- ai the: vet loet thng nho ng knh < 5mm, nong, mau trang xam, b ro, xung
quanh co vien o, thng nep li - ma, au va b li.
- Vi the: niem mac mieng vung ton thng khi au tham nhap te bao viem n nhan, sau
o la bach cau a nhan trung tnh khi co boi nhiem. (Hnh 1)
Hnh 1: Vet loet nong trong viem loet mieng apt. Hnh 2: Mang trang mieng do nhiem nam candida.
B. Nhiem nam
Dch te hoc: Thng do nam Candida albicans, loai nam nay co the van thng tru trong
khoang mieng (30-40% dan so) nhng ch tr thanh tac nhan gay benh nhng ngi b suy
giam mien dch do benh tieu ng, thieu mau, dung khang sinh hay corticoid keo dai, ung th.
Hnh thai ton thng:
- ai the: ton thng co dang mang trang nh vang sa, dnh, b ro; khi b cao i, e lo
nen mo viem o ben di.
- Vi the: mang trang cha vo so the nam (si nam, bao t). (Hnh 2)
C. Nhiem virut Herpes
Dch te hoc: Viem mieng do virut Herpes (hau het la HSV typ1) la benh rat thng gap.
Tren 3/4 dan so tuoi trung nien co mang mam benh trong mieng nhng ch mot so t trng hp
la co bieu hien lam sang do virut c tai hoat hoa Sot, nhiem lanh, nang, gio, nhiem trung ho
hap, d ngeu co the tai hoat hoa virut.
Hnh thai ton thng
- ai the: ton thng la mot hay nhieu bong nc, kch thc < 5mm, cha dch trong. Ton
thng thng moi, quanh lo mui, gay au. Cac bong nc nay co the v tao vet loet nong,
lanh sau vai tuan nhng thng tai phat.
- Vi the: te bao bieu mo b nhiem virut phong to, trong nhan cha the vui ai toan. oi khi
cac te bao gan nhau hp thanh ai bao nhieu nhan. Cac te bao nay nam vach bong nc
hoac troi l lng trong dch bong nc.
II. BACH SAN (Leukoplakia):
Bach san la cac mang trang niem mac mieng, gii han ro, khong cao troc c; tao bi
s tang sinh bieu mo phu. Bach san c xem la ton thng tien ung v co 5-6% trng hp se
chuyen thanh ung th.
Dch te hoc: mang nay thng gap ngi ln tuoi, lien quan chat che vi viec dung
thuoc la, uong ru, dung thc an kch thch, viem man tnh hoac nhiem HPV.
Hnh thai ton thng:
- ai the: ton thng co dang mot hoac nhieu mang trang, go cao; be mat trn lang hoac
san sui; cng; xuat hien niem mac ma, san mieng, bung li.
- Vi the: co hien tng tang sng, tang gai cua lp bieu mo lat tang niem mac mieng.
Bieu mo nay co the chuyen dang thanh nghch san va sau o la carcinom tai cho. (Hnh 3)
Hnh 3: Bach san b li (A); Bieu mo day len do hien tng tang gai va tang sng (B)
III. UNG TH KHOANG MIENG VA LI
Loai ung th thng gap nhat cua khoang mieng va li la carcinom te bao gai.
Dch te hoc: thng xay ra sau 40 tuoi.
Yeu to nguy c cua ung th mieng: bach san; dung thuoc la (ac biet la thoi quen an trau
xa thuoc); nghien ru; nhiem HPV typ 16,18.
Hnh 4: Ton thng sui loet niem mac mieng (A); Cac am te bao gai xam nhap mo em (B)
Hnh thai ton thng:
- ai the: ton thng choi sui, loet be mat, co the b boi nhiem.
- Vi the: cac am te bao gai co nhan d dang, hach nhan to, phan bao bat thng, xep
thanh o, xam nhap mo em ben di. (Hnh 4)
Lien he lam sang: Khi phat khong au nen thng phat hien tre, nhat la khi ton thng
nam 1/3 sau li; lam giam ket qua ieu tr va kha nang song con cua benh nhan.
TUYEN NC BOT
Tuyen nc bot bao gom cac tuyen chnh la tuyen mang tai, tuyen di ham va tuyen di
li, ngoai ra con co cac tuyen nc bot phu nam rai rac trong niem mac mieng va niem mac
vom khau cai. Benh ly tuyen nc bot hay gap tuyen mang tai. Hai loai benh ly thng gap
nhat la la viem va u tuyen nc bot.
I. VIEM TUYEN NC BOT
Viem tuyen nc bot co the do virut, vi khuan, hay do nguyen nhan t mien; trong o
nhiem virut quai b (paramyxovirus) la nguyen nhan thng gap nhat. Benh quai b tre em co
ton thng gii han tuyen nc bot; trai lai ngi trng thanh th co the b bien chng viem
tuy va viem tinh hoan (dan en vo sinh ve sau).
A. Viem tuyen nc bot do virut quai b
Hnh thai ton thng:
- ai the: Paramyxovirus gay sng to toan
bo cac tuyen chnh, ac biet la tuyen mang tai.
- Vi the: Paramyxovirus thng gay viem
mo ke lan toa, phu va tham nhap te bao n
nhan; oi khi co cac o hoai t.
B. Viem tuyen nc bot do c che t mien
trong hoi chng Sjgren th hau nh luon tan
cong hai ben. Tat ca tuyen nc bot (chnh va
phu), tuyen le eu b ton thng, gay ra chng Hnh 5: Viem tuyen nc bot man tnh do tac ong
kho mieng va kho mat (viem ket - giac mac dan. Mot so nang tuyen b teo, mo em
kho) tham nhap lympho bao va tng bao.
C. Viem tuyen nc bot do vi khuan thng xay ra th phat sau tac ong tuyen do soi (Hnh 5).
Vi khuan gay benh thng gap nhat la Staphylococcus aureus va Streptococcus viridans. Phan
ng viem xay ra trong mo ke, co the gay hoai t hoa mu, hnh thanh o ap-xe.
II. U TUYEN NC BOT

Dch te hoc: noi chung, u tuyen nc bot tng oi t gap, chiem khong qua 2% cac loai u
ngi. T le nam n mac benh nh nhau; xay ra ngi ln nhieu hn tre em. U thng xuat
hien tuyen mang tai, chiem 65-80% trng hp, trong o co khoang 15% la ac tnh; 10% u
xay ra tuyen di ham trong o co 40% la ac tnh; so t con lai xuat hien tuyen nc bot
di li va cac tuyen nc bot phu nhng qua na la u ac. Nh vay, t le u ac tnh cua u tuyen
nc bot t le nghch vi kch thc tuyen.
Dang ai the thng thay la 1 khoi u trc tai, thng di ong khi s nan, kch thc t 4-
6cm. Ch co the chan oan phan biet lanh ac mot cach chac chan bang khao sat mo benh hoc.
Hai loai u lanh tuyen nc bot thng gap la u tuyen a dang va u Warthin. Loai u ac nguyen
phat thng gap nhat cua tuyen nc bot la carcinom nhay b.
A. U tuyen a dang (pleomorphic adenoma, mixed tumor):
Con goi la u hon hp, la u lanh thng gap tuyen mang tai.
Hnh thai ton thng:
- ai the: u lanh, phat trien cham, kch thc < 6 cm. b tng oi ro, co vo bao si, be
mat trn lang
- Vi the: u c ac trng bi s a dang ve thanh phan cau tao. Thanh phan bieu mo
gom cac te bao nho hnh tron hoac hnh thoi, sap xep thanh cau truc ong, tui, day, am ac.
Thanh phan bieu mo hoa tron vi mo em dang niem, long leo, oi khi cha cac ao dang sun
hoac xng. Bang chng hoa mo mien dch cho thay tat ca cac loai te bao khac nhau nay trong
u eu xuat phat t te bao c bieu mo. (Hnh 6)
Lien he lam sang: u phat trien cham, khong au nen benh nhan thng e nhieu nam mi i
kham benh. U thng xuat phat t thuy nong tuyen mang tai, tao ra mot khoi phong goc ham
s thay de dang. U co vo bao khong hoan toan nen de tai phat neu phau thuat cat bo khong u
rong. Khoang 2-3 % cac trng hp tai phat hoa ac, goi la carcinom tren nen u tuyen hon hp
(carcinoma ex mixed tumors).
Hnh 6 : U tuyen a dang tuyen nc bot co gii han ro (A). Cau tao vi the gom nhieu thanh phan nh cac
ong tuyen (1), mo em dang niem (2) (B).
B. U Warthin
La u lanh, hau nh ch xuat hien tuyen mang tai.
Hnh thai ton thng:
- ai the: thng la khoi nho, tron hay bau duc, co vo bao, mat cat mau trang xam, thng
co cac khe hoac boc nho cha dch nhay hoac dch thanh.
- Vi the: co 2 hnh anh ac thu (Hnh 7A):
* Lp bieu mo co 2 lp te bao ai toan lot trong cac khoang boc, phan nhanh.
* Mo limpho ben di bieu mo rat phat trien, oi khi tao thanh nang limpho.
Hnh 7: U Warthin: bieu mo 2 lp (1),i mo limpho ben di tao thanh nang limpho vi trung tam mam (2)(A)
Carcinom nhay b gom cac am te bao tiet nhay (1) va te bao gai (2) (B).
C. Carcinom nhay b (mucoepidermoid carcinoma):

La loai u ac nguyen phat tuyen nc bot thng gap nhat, thng xay ra tuyen mang tai.
Hnh thai ton thng:
- ai the: u co kch thc t 1-8 cm, gii han ro, chac, di ong kem, co the gay au neu co
xam nhiem than kinh.
- Vi the: u khong co vo bao, xam nhap vao mo tuyen nc bot xung quanh; mat cat trang
xam, thng co vai boc nho cha chat nhay. Cau tao cua u gom cac te bao gai va te bao tiet
nhay, sap xep thanh dai, be hoac bao quanh cac boc nho (Hnh 7B). Carcinom nhay b c
phan loai grad mo hoc thap, va hay cao tuy theo t le thanh phan te bao gai trong u, s d dang
te bao, mc o phan bao va hoai t; grad mo hoc cang cao th u co o ac tnh cang ln, xam
nhap tai cho va cho di can xa cang nhanh.
THC QUAN
Thc quan la 1 ong c noi gia vung hau va tam v cua da day, dai 10 cm tre s sinh va
23 en 25 cm ngi ln. au tren cua thc quan, c nhan hau tao thanh c that thc quan
tren; oan di cua thc quan ngang vi c hoanh, dai khoang 2-4 cm, tao thanh c that thc
quan di. Thanh thc quan gom 4 lp: niem mac, di niem mac, c va ao ngoai. Lp niem
mac c lot bi bieu mo lat tang khong sng hoa; lp ao ngoai khong tao ra c 1 lp thanh
mac thc s nh trong phan con lai cua ong tieu hoa, chnh v vay, cac ton thng nhiem khuan
va ung th cua thc quan de lan rong vao trung that sau, en cac tang khac trong long ngc.
Thc an nuot vao c a xuong da day nh vao s phoi hp nhp nhang gia cac nhu ong
thc quan va hoat ong ong m cua c that thc quan di.
Cac ton thng cua thc quan kha a dang: viem, u, trng n tnh mach nhng lai co
trieu chng kha giong nhau: kho nuot, nong rat sau xng c, oi mau. V vay, e chan oan
chnh xac cac loai ton thng thc quan, phai phoi hp nhieu phng phap khac nhau nh noi
soi sinh thiet, chup X-quang co can quang thc quan, o ap lc long thc quan. Sau ay la cac
loai benh ly thng gap cua thc quan.
I. XC THC QUAN (lacerations) :
Thng gap ngi nghien ru, tnh
trang non ma qua mc sau uong ru co the
gay ra cac vet xc doc tai cho noi thc quan
- da day, con goi la vet xc Mallory - Weiss,
co chieu dai thay oi t vai mm en vai cm.
Vet xc co the ch nong lp niem mac
hoac sau ti mc xuyen thau thanh thc quan.
Ve mat vi the, co hien tng xuat huyet tai b
vet xc, tham nhap te bao viem; dien tien noi
chung nhe nhang, lng mau oi ra khong
nhieu, t khi phai can thiep ngoai khoa; cac vet
xc se lanh va khong e lai di chng (Hnh
8). Hnh 8: Vet xc thc quan (mui ten)
II. TRNG N TNH MACH THC QUAN (varices):
La hau qua cua tnh trang tang ap lc tnh mach ca do x gan (chu yeu la x gan ru);
mau t tnh mach ca phai i vong theo cac nhanh tnh mach bang he, nam trong lp niem mac
va di niem cua oan di thc quan e tr ve tim, ket qua la cac tnh mach nay se b trng
n dan do s gia tang ap lc mau trong long mach.
Cac tnh mach trng n chay ngoan ngoeo, tap trung chu yeu trong lp di niem mac
cua oan 1/3 di thc quan; lp niem mac b ay nho vao long thc quan nen de b viem loet,
co the lam v tnh mach thc quan gay oi mau o at; ay cung la nguyen nhan gay t vong
thng gap cac benh nhan x gan. (Hnh 9)
Hnh 9: Cac tnh mach trng n ngoan ngoeo (mui ten, A); Cac tnh mach trong lp di niem
mac gian rong cha ay hong cau (B)
III. VIEM THC QUAN (esophagitis):
Viem thc quan la mot benh ly rat thng gap ngi ln nhng t thay tre em. Viem
thc quan co the do nhieu nguyen nhan khac nhau:
- Trao ngc dch v len thc quan: la nguyen nhan hang au, dch v co tnh acid lam ton
thng niem mac thc quan, gay ra tnh trang viem thc quan (viem thc quan trao ngc)
(reflux esophagitis)
- Cac tac nhan kch thch nh at ong thong da day qua lau; dung cac chat kch thch nh
ru, cac dung dch acid hoac kiem, thc uong qua nong, cac hoa chat ieu tr ung th, tia xa
- Cac tac nhan nhiem trung nh vi khuan, virut (HSV), nam.
Hnh thai ton thng:
- ai the: thay oi tuy loai viem thc quan, thi gian va mc o tac ong cua tac nhan
gay viem. oi vi viem thc quan trao ngc; neu viem nhe, ch thay niem mac thc quan sung
huyet hi o; trng hp viem nang, niem mac co the b loet, hoai t, xuat huyet, hnh thanh mo
hat viem va hoa x gay hep long thc quan.
- Vi the:
Trong trng hp viem thc quan trao
ngc mc o nhe, co 3 hien tng sau:
* Tham nhap cac te bao viem trong lp
bieu mo nh bach cau a nhan ai toan (xuat
hien sm nhat), BCNTT, limpho bao.
* Tang san lp ay bieu mo (>20%
chieu day bieu mo).
* Cac nhu cua mo em niem mac b
sung huyet, nho cao en 1/3 tren lp bieu
mo (Hnh 10).
Lien he lam sang: Trieu chng cua
viem thc quan thay oi tuy theo mc o
viem, gom co chua, cam giac nong rat sau H.10: Tang san lp ay bieu mo (mui ten dai) va
xng c, kho nuot, oi mau, i cau phan en. tham nhap bach cau ai toan (au mui ten)
Viem thc quan trao ngc keo dai co the dan en thc quan Barrett cung vi nguy c hoa ac
cua no.
IV. THC QUAN BARRETT

La bien chng cua tnh trang trao ngc keo dai cua dch v len thc quan. Trong thc
quan Barrett, lp bieu mo lat tang khong sng hoa bnh thng oan di thc quan c
chuyen san thanh bieu mo tru tiet nhay (kieu da day - ruot), co le e thch nghi tot hn vi moi
trng acid gay nen bi s trao ngc dch v.
Hnh 11: Vung niem mac o mt cua thc quan Barrett (A) Bieu mo lat tang cua thc quan c thay the
bi bieu mo tru kieu da day - ruot.
Hnh thai ton thng:
- ai the: bieu hien cua thc quan Barrett la mot vung niem mac co mau o mt, xuat
hien cho noi thc quan - da day, chay vong het chu vi long thc quan hoac phan bo thanh
nhieu am rai rac; tng phan ro ret vi mau hong nhat cua niem mac thc quan bnh thng
pha tren va mau hong nau cua niem mac da day ben i.
- Vi the: bieu mo lat tang khong sng hoa cua thc quan b thay the bi bieu mo tru tiet
nhay (kieu da day - ruot); trong o co the tm thay nhng vung b nghch san t nhe en nang,
vi hnh anh nhan tang sac, xep chong chat len nhau. (Hnh 11)
Lien he lam sang: ngi b thc quan Barrett co nguy c carcinom tuyen thc quan tang
30-40 lan so vi ngi bnh thng, do lp bieu mo tru chuyen san co the b nghch san, roi
chuyen thanh ung th.
V. U THC QUAN
U lanh tng oi t gap, ch chiem khoang 5% cac loai u thc quan. Hau het cac u lanh
nay co nguon goc t trung mo; trong o u c trn la loai thng gap nhat. U ac thc quan, theo
so lieu ghi nhan 2004-2008, la loai ung th ng hang th 8 va th 5 trong cac loai ung th cua
gii nam thanh pho Ho ch Minh va Ha noi, nhng khong nam trong so 10 loai ung th thng
gap nhat cua gii n ca 2 thanh pho. Ung th thc quan co dien tien am tham, khi phat hien
th thng a qua tre khong con kha nang phau thuat, kha nang song them 5 nam cua benh
nhan ch vao khoang 5%. Carcinom te bao gai thng gap nhat, chiem t le 90% u ac thc quan;
so con lai la carcinom tuyen va mot so loai hiem gap khac nh melanom, carcinoid Hien nay,
t le carcinom tuyen oan 1/3 di thc quan co khuynh hng tang len; co le nh vao
phng tien noi soi giup phat hien nhieu hn cac trng hp thc quan Barrett, qua o xac nh
c carcinom tuyen tai ay la cua thc quan hn la cua da day xam nhap len.
A. Carcinom te bao gai thc quan

Dch te hoc: carcinom te bao gai thc quan chiem 6% ung th ong tieu hoa; thng gap
tuoi sau 50; xuat o mac benh gii nam nhieu hn gii n t 2/1 en 20/1. Mot so yeu to nguy
c c ghi nhan:
- Benh ly thc quan: viem thc quan keo dai, hoi chng Plummer - Vinson (mang thc
quan, thieu mau nhc sac, viem teo li).
- Uong ru, hut thuoc la, nhai trau.
- Che o an thieu vitamin (A,C, riboflavin, thiamin, pyridoxin), thieu yeu to vi lng kim loai
(kem, molybdenum), thc an b nhiem nam hoac co cha nitrosamines.
- Mot so c a di truyen: chng da day sng (tang sng long ban tay va ban chan).
Hnh thai ton thng:
- ai the: v tr ung th: 20% 1/3 tren, 50% 1/3 gia va 30% 1/3 di thc quan.
Khi au la 1 vung day len cua niem mac co mau trang xam; sau khoang thi gian t vai
thang en vai nam, ton thng phat trien thanh cac dang sau (rieng biet hoac phoi hp):
- Dang choi sui nho vao long ong (60%).
- Dang loet (25%) do khoi u b hoai t, an sau xuong ben di; co the lam thung cay phe
quan, ong mach chu, hoac mang bao tim.
- Dang tham nhiem lan toa (15%) lam day cng thanh thc quan va hep long ong.
- Vi the: hau het la carcinom te bao gai co o biet hoa tot hoac va. (Hnh 12)
Lien he lam sang: dien tien ban au am tham, ve sau mi co trieu chng kho nuot ngay
cang tang (nghen ac sac long), benh nhan b suy dinh dng do an uong kem, co the b xuat
huyet hoac nhiem khuan nhiem oc do khoi u l loet hoai t. Khi c phat hien, u thng a
qua ln, xam nhap nen kho phau thuat c; ngay ca khi co the cat bo, t le tai phat tai cho va
di can xa cung cao. Ung th 1/3 tren thng di can en hach co, 1/3 gia en hach trung that va
hach canh kh quan, 1/3 di en hach than tang (Celiac) va hach quanh da day.
Hnh 12 : Carcinom te bao gai thc quan dang sui loet (A); Cac am te bao gai biet hoa va xam nhap (B).
B. Carcinom tuyen
Hau nh tat ca cac trng hp carcinom tuyen thc quan eu xuat hien tren nen thc
quan Barrett, vi t le ngay cang tang; My, t le nay ngang bang vi carcinom te bao gai. Benh
nhan thng tren 40 tuoi, xuat o mac benh cua gii nam cao hn gii n.
Hnh thai ton thng:
- ai the: thng xuat hien tren nen thc
quan Barrett , 1/3 di cua thc quan va co the
xam lan xuong tam v cua da day. Ton thng
ban au co dang phang hoac hi go len vi lp
niem mac ben tren con nguyen ven, ve sau phat
trien thanh khoi ln san sui hoac xam nhiem lan
toa hoac loet sau xuong ben di. (Hnh 13)
- Vi the: a so la carcinom tuyen tiet nhay
giong carcinom tuyen cua ruot, o biet hoa tot,
va hoac kem; cac te bao tuyen ac tnh d dang,
nhan tang sac; tao thanh ong tuyen hoac cac
am ac tuy theo o biet hoa. Mot so rat t trng
hp co dang ung th te bao mat nhan cua da
day.
Hnh 13: Carcinom tuyen thc quan
DA DAY
Da day la 1 c quan hnh tui co dung tch t 1200 - 1500 ml, la ni nhao tron thc an vi
dch v. Ve mat giai phau hoc, da day c chia thanh 5 phan: tam v, ay v, than v, hang v va
mon v; tai mon v lp c trn day len tao thanh c that mon v. Thanh da day gom 4 lp: niem
mac, di niem mac, c trn va thanh mac. Toan bo niem mac c phu bi bieu mo tru n
tiet nhay, trong mo em co cha cac tuyen da day khac nhau tuy vung, gom 3 loai: tuyen tam v
va tuyen hang - mon v tiet nhay; tuyen v phan bo trong vung ay v va than v, cau tao gom te
bao chnh va te bao vien, san xuat ra pepsin va HCl, la thanh phan chnh cua dch v. Toan bo
chat nhay c tiet ra se tao thanh hang rao bao ve niem mac chong lai tac ong tieu hoa cua
dch v.
Ve mat benh ly hoc, co the gap cac ton thng viem, loet, u va mot so d tat bam sinh t
gap nh hep mon v ph ai, thoat v hoanh, v.v.
I. VIEM DA DAY
La tnh trang viem niem mac da day. Viem da day co the cap tnh hoac man tnh.
A. Viem da day cap tnh (acute gastritis):
La tnh trang viem cap tnh niem mac da day; dien tien thng nhe nhang nhng oi khi
co loet trt niem mac hoac nhng o loet thc s (con goi la loet do stress); a en xuat huyet
tieu hoa (oi mau, i cau phan en).
Nguyen nhan va c che benh sinh:
Nhieu tac nhan khac nhau co the gay ra viem da day cap tnh: cac thuoc giam au khong
steroid nhat la aspirin, ru, cac dung dch acid hoac kiem, cac thuoc hoa tr ung th, tia xa, tnh
trang stress (do chan thng nang, bong), nhiem khuan nhiem oc hoac soc. Cac tac nhan nay
trc tiep lam ton thng cac te bao bieu mo, hoac gian tiep thong qua s kch thch tang tiet
acid, giam san xuat chat em bicarbonat HCO3-, pha v lp chat nhay bao ve, giam lng mau
nuoi niem mac.
Hnh thai ton thng:
Thay oi khac nhau tuy mc o viem.
Trng hp viem nhe: niem mac da day sung huyet o; di KHVQH, niem mac co mo
em b phu ne sung huyet, bieu mo ben tren van con nguyen ven nhng co s tham nhap cua
nhieu BCNTT vao gia cac te bao bieu mo.
Trng hp viem nang hn: niem mac b loet trt (erosion) va xuat huyet tao thanh nhng
om mau nau tren nen sung huyet o; trong trng hp b loet do stress, cac o loet hnh tron,
nho (ng knh < 1cm), b va ay o loet van mem mai, phan bo rai rac moi vung da day.
Di KHVQH, loet trt la nhng vung niem mac b mat chat nhng cha sau qua lp c niem,
mo em niem mac phu ne, tham nhap nhieu BCNTT, co the tu thanh dch xuat mu - t huyet
phu len tren be mat niem mac. oi vi o loet do stress ( benh nhan b bong hay chan thng
nang), ton thng mat chat cung vi hien tng xuat huyet va tham nhap te bao viem co the an
sau xuong en lp di niem mac. (Hnh 14)
Hnh 14 : Viem da day cap tnh do stress vi nhng o loet trt xuat huyet rai rac (A), niem mac phu ne,
tham nhap BCNTT, co dch xuat mu - t huyet tren be mat bieu mo (B)
Lien he lam sang: trng hp viem da day cap tnh nhe, benh nhan co the ch thay hi
kho chu hoac au vung thng v, co the co cam giac buon non hoac oi. Trng hp viem
nang co loet trt hoac loet, benh nhan co the oi ra mau va i cau phan en. Khi tac nhan gay
viem a b loai bo, cac vet loet trt va o loet se lanh hoan toan, khong e lai di chng.
B. Viem da day man tnh (VDDMT) (chronic gastritis):
nh ngha: la tnh trang viem man tnh niem mac da day, dan en s teo et niem mac va
chuyen san bieu mo, nhng thng khong gay loet trt nh trong viem cap tnh.
Nguyen nhan:
Hai tac nhan chnh gay ra VDDMT:
- Tnh trang nhiem khuan man tnh Helicobacter pylori: H.pylori la 1 loai vi khuan gram am
hnh que hi cong, dai khoang 3,5 m. Vi khuan co cac roi giup no di chuyen trong lp chat
nhay cua da day, gan len be mat cac te bao bieu mo va san xuat ra cac oc to lam ton thng
niem mac da day. Co the tm thay H.pylori trong vung hang v cua 90% so benh nhan VDDMT.
- Phan ng t mien chong lai te bao vien cua tuyen v: la nguyen nhan gay benh cua 10%
so benh nhan VDDMT. nhng ngi nay, s hien dien cua cac t khang the chong te bao
vien se pha huy cac tuyen v, lam teo et niem mac da day, lam giam s san xuat acid va yeu
to noi tai (can cho s hap thu vitamin B12 tai hoi trang); ket qua benh nhan se b thieu mau ac
tnh (pernicious anemia) do thieu vitamin B12.
Ton thng te bao bieu mo tuyen da day, du do H.pylori hoac do khang the t mien, se
thu hut cac limpho bao va tng bao tham nhap vao lp niem mac, cac te bao viem nay c
hoat hoa san xuat ra cac chat trung gian hoa hoc co the lam ton thng them niem mac, tao ra
cac bien oi hnh thai cua VDDMT.
Hnh thai ton thng:
- ai the: v tr ton thng khac nhau tuy theo nguyen nhan gay benh: VDDMT do phan
ng t mien co ton thng chu yeu niem mac vung than - ay v (ni cha cac tuyen v); ton
thng trong VDDMT do H.pylori th lai c thay chu yeu vung hang v.
Trong giai oan au cua viem man tnh, niem mac da day co mau o, day len, lam tang
kch thc cac nep gap niem mac; khi a chuyen sang giai oan teo et, lp niem mac mong i
va xep xuong.
Hnh 15: VDDMT do H.pylori, bieu mo da day co vi khuan tren be mat, co vung chuyen san ruot (mui ten,
A1); mo em tham nhap limpho bao, co nang limpho (A2). VDDMT do phan ng t mien, niem mac
b teo et dan do giam so lng tuyen (B1) va co hien tng chuyen san ruot (mui ten B2).
- Vi the: VDDMT do H.pylori hoac do phan ng t mien eu co nhng ac iem vi the sau
(Hnh 15):
- Tham nhap limpho bao va tng bao trong mo em cua niem mac; cac limpho bao co
the tap hp lai thanh cac nang limpho s cap hoac th cap trong lp niem mac.
- Tang sinh tai tao cac tuyen b ton thng, bieu hien qua s gia tang hnh anh phan bao
trong cac tuyen niem mac, s hien dien cua cac te bao tuyen tang sinh co nhan to, tang sac
(nhieu khi kho phan biet vi cac te bao nghch san).
- Chuyen san ruot: bieu mo da day vung hang v, than - ay v c thay the bi cac te
bao tru co vi nhung mao va te bao hnh ai tiet nhay.
- Teo et niem mac : do cac tuyen da day b pha huy, giam so lng.
- Nghch san: co the xuat hien nhng trng hp VDDMT keo dai lau nam; cac te bao
bieu mo nghch san co hnh dang va kch thc thay oi, nhan to tang sac, nh hng sap xep
b roi loan. Mc o nghch san thay oi t nhe en nang, co ni bien thanh carcinom tai cho.
10% cac trng hp nghch san va va nang se phat trien thanh ung th da day sau 1 khoang
thi gian t 1-6 nam. Chnh v vay, can theo doi e phat hien kp thi cac ton thng nghch san
cac trng hp VDDMT.
Lien he lam sang: bieu hien lam sang cua VDDMT kha ngheo nan nh buon non, oi ma,
kho chu hoac au nhe vung thng v. oi vi VDDMT do H.pylori, do van con mot so lng te
bao vien cha b pha huy nen nhng benh nhan nay khong b vo toan da day hoac thieu mau
ac tnh; ngc lai vi VDDMT do phan ng t mien, hau het te bao vien b pha huy nen benh
nhan se b vo toan da day va khoang 10% trong so o se b thieu mau ac tnh. ieu ang quan
tam hn ca la kha nang chuyen thanh carcinom da day t cac ton thng nghch san xuat hien
trong VDDMT.
II. LOET DA DAY-TA TRANG MAN TNH (LDDTTMT ) (peptic ulcer):
Loet do tac ong cua acid va pepsin trong dch v (peptic ulcer) la nhng o loet man tnh,
n oc; co the xuat hien bat ky oan nao cua ong tieu hoa nhng ai a so eu tap trung
vao oan au ta trang hoac da day. Chnh v vay, cum t loet da day-ta trang man tnh
(LDDTTMT) c xem ong ngha vi loet do tac ong cua acid va pepsin trong dch v.
Dch te hoc :
LDDTTMT la 1 benh ly man tnh, dai dang, tai i tai lai. Benh thng gap ngi ln; xuat
o mac benh gii nam cao hn gii n t 2-3 lan. Phu n thng b LDDTTMT vao giai oan
man kinh hoac sau man kinh.
LDDTTTMT la hau qua cua tnh trang mat can bang gia cac c che bao ve niem mac da
day - ta trang va tac ong tieu hoa cua acid va pepsin trong dch v.
Cac c che bao ve niem mac da day-ta trang gom:
- S tiet nhay cua te bao bieu mo be mat, tao ra lp chat nhay phu tren be mat niem
mac.
- Cac te bao bieu mo be mat che tiet bicarbonat HCO3- vao trong lp chat nhay, tao ra vi
moi trng pH trung tnh cho be mat te bao.
- Cac te bao bieu mo co kha nang tang sinh tai tao nhanh chong, thay the cac te bao b
ton thng, am bao s toan ven lp bieu mo be mat.
- He thong ti mau niem mac phong phu, cung cap oxy, bicarbonat va cac chat dinh
dng can thiet cho bieu mo, ong thi chuyen i cac ion H+ b khuyech tan ngc t long ong
vao trong niem mac, duy tr tot hoat ong chuyen hoa te bao va tai tao.
- Mo em niem mac san xuat prostaglandin, kch thch s tiet nhay va bicarbonate, duy tr
viec ti mau niem mac.
Co nhieu tac nhan co the gay ra s mat can bang gia c che bao ve niem mac va tac
ong cua acid-pepsin, dan en LDDTTTMT nh: H.pylori, thuoc la, ru, thuoc khang viem
khong steroid, corticoid, u san xuat gastrin (gastrinoma).
H.pylori la tac nhan quan trong nhat, gay ra tnh trang mat can bang tren. No c tm
thay hau het cac benh nhan b loet ta trang va 70% benh nhan loet da day. C che tac ong
cua H.pylori rat phc tap:
- H.pylori san xuat protease lam huy glycoprotein trong chat nhay da day.
- H.pylori san xuat phospholipases lam ton thng te bao bieu mo be mat, giai phong cac
chat trung gian hoa hoc thu hut va hoat hoa cac te bao viem, lam niem mac cang b ton thng
hn na, khien s san xuat chat nhay cang giam.
- Yeu to hoat hoa tieu cau do H.pylori san xuat thuc ay s hnh thanh huyet khoi lam tac
nghen cac mach mau nuoi niem mac.
- H.pylori kch thch s tiet gastrin, lam tang san xuat acid.
Chnh v vay, khi dung khang sinh tieu diet H.pylori, o loet se mau lanh hn va t b tai
phat.
Hnh thai ton thng:
- ai the: trong benh LDDTTMT, o loet thng ta trang hn da day, vi t le 4:1. V tr
thng thay nhat cua o loet ta trang la oan ngan vai cm ngay sau c that mon v, thanh
trc nhieu hn thanh sau. V tr thng thay nhat cua o loet da day la b cong nho, gan cho
khuyet goc (incisura angularis), t gap thanh trc, thanh sau va b cong ln. a so benh
nhan ch co 1 o loet; khoang 10 - 20% so benh nhan co ong thi o loet da day va ta trang.
O loet co hnh tron hoac bau duc, a so co ng knh nho hn 2cm nhng 10% trng hp co
ng knh > 4cm; vach o loet dng ng; b o loet khong go cao nh trong cac ton thng ac
tnh. ay o loet thng nhan va sach, nh hoat ong tieu hoa cua dch v lam phan huy cac dch
viem; co the e lo ra cac mach mau a c bt lai bang cuc huyet khoi. o sau cua o loet con
gii han lp niem mac va di niem mac, hoac a an sau en lp c. Trng hp o loet
xuyen thung toan bo vach da day, ay o loet co the c bt lai bang mac noi, gan, tuy. Khi o
loet lanh va hoa seo, no co the gay co keo, tao ra cac nep gap niem mac toa ra xung quanh
theo hnh nan hoa hoac gay hep mon v. (Hnh 16)
Hnh 16: O loet da day (A) va ta trang (B), co vach dng ng, b khong go cao, ay sach.
- Vi the : hnh anh vi the co the thay oi tuy theo o loet ang trong thi iem viem hoai
t, viem man tnh hoac ang lanh seo. Tai o loet ang b hoai t tien trien, co the phan biet ro 4
vung t nong en sau (Hnh 17):
Hnh 17: Bon vung cua o loet

+ B va ay o loet c phu mot lp mong nhng manh vun hoai t dang t huyet (fibrinoid).
+ Ben di lp nay la vung tham nhap te bao viem khong ac hieu ma chu yeu la BCNTT.
+ Sau hn la mo hat viem vi cac te bao n nhan.
+ Di cung la mo seo co nhieu si collagen, trai rong en b o loet. Mach mau trong vung
nay co thanh day la do hien tng viem bao quanh va thng b huyet tac huyet khoi.
O loet c lam lanh nh vao s tai tao lp niem mac t b o loet, phu len tren mo seo giau si
collagen.
Lp niem mac xung quanh o loet thng co hnh anh viem da day man tnh (85-100%
trng hp loet ta trang va 65% loet da day). ieu nay giup phan biet vi loet trt va loet do
stress trong viem da day cap, lp niem mac xung quanh van con tng oi bnh thng.
Lien he lam sang:

Cac trieu chng chnh cua LDDTTMT la chua, au vung thng v, au tang len sau ba
an va ve em. Cac bien chng chnh cua LDDTTMT gom co xuat huyet gay oi mau va i cau
phan en; thung gay viem phuc mac; hoa seo gay hep mon v.
LDDTTMT la mot benh man tnh, dai dang, tai i tai lai; tuy khong rut ngan i song nhng lai
lam suy giam nghiem trong chat lng cuoc song cua benh nhan. Neu khong c ieu tr th
trung bnh phai mat 15 nam, o loet mi co the lanh c. Loet ta trang khong bao gi hoa ac;
mot vai trng hp loet da day hoa ac co le xuat phat t bieu mo nghch san trong viem da day
man tnh i kem vi loet da day hn la t chnh ban than o loet.
III. U DA DAY
U da day thng xuat phat t bieu mo. U thng c chia thanh 2 nhom la polyp va
carcinom. Trong so cac u ac tnh da day, thng gap nhat la carcinom chiem t le 90-95%;
ngoai ra, con co limphom (chiem 4%), carcinoid (3%), u mo em da day - ruot (Gastro-Intestinal
Stromal Tumor - GIST) (2%).
A. Polyp da day
Polyp da day t gap, thng c phat hien mot cach tnh c trong khi lam noi soi da day
(khoang 2-3% cac trng hp noi soi) e tm nguyen nhan gay xuat huyet tieu hoa. Phan biet 2
loai:
- Polyp tang san (hyperplastic polyp): chiem hn 90% cac polyp da day. ay la mot ton
thng gia u, thng xuat hien tren nen viem da day man tnh, rat hiem khi hoa ac. Polyp tang
san thng nho, ng knh khong qua 2cm, be mat lang, co hoac khong co cuong. Cau tao vi
the gom bieu mo be mat tang san lanh tnh; ben trong la mo em phu ne, tham nhap cac te bao
viem va co cha cac tuyen gian rong.
- U tuyen dang polyp (adenomatous polyp): con goi la polyp tuyen, chiem 5 -10% cac
polyp da day. U thng hang v, n oc, ng knh 3-4cm, co hoac khong co cuong. ay la
u thc, co the cha bieu mo nghch san, v vay co tiem nang ac tnh. Khi khao sat ky, 8-59% u
tuyen dang polyp co cha mot o carcinom. (Hnh 18)
Hnh 18: ai the va vi the cua mot u tuyen dang polyp da day.
B. Carcinom da day
Dch te hoc: carcinom da day la loai ung th pho bien tren toan the gii va c xep vao
nhom 10 loai ung th thng gap nhat. Xuat o ung th da day thay oi tuy theo vung a d;
Nhat, Trung quoc, Nga, Colombia la cac quoc gia co xuat o carcinom da day rat cao, gap 4-6
lan xuat o Anh, My, Phap. So lieu cua Viet nam (2004-2008) cho thay ung th da day ng
hang th 4 va 8 oi vi gii nam va n cua thanh pho Ho ch Minh; hang th 2 va 3 oi vi gii
nam va n thanh pho Ha noi.
Phan loai: theo hnh thai mo hoc, phan biet 2 loai carcinom da day: kieu ruot va kieu lan
toa. Carcinom kieu ruot xay ra benh nhan co tuoi trung bnh la 55 tuoi; nam b nhieu hn n (t
le 2:1); loai carcinom nay co xu hng biet hoa tot va c cho la xuat phat t bieu mo nghch
san trong VDDMT. Carcinom kieu lan toa xay ra benh nhan tre hn, trung bnh 48 tuoi, va
khong co s khac biet ve gii (t le 1:1). loai nay co xu hng biet hoa kem, khong co moi lien
he vi VDDMT va c cho la xuat phat t cac ot bien mi (de novo) cua cac te bao tiet nhay
trong tuyen da day.
Benh sinh: cac yeu to moi trng c cho la gi vai tro chnh lam phat sinh ung th da
day, yeu to c a di truyen thuan li ch ong vai tro th yeu.
- oi vi carcinom tuyen kieu ruot: a xac nh c cac yeu to nguy c lam phat sinh
ung th nh che o an qua nhieu muoi hoac gia v, cac thc pham che bien co s dung nitrat
lam chat bao quan; viem da day man tnh do H.pylori.
- oi vi carcinom kieu lan toa: cha xac nh c cac yeu to nguy c. Ung th xuat hien
khong thong qua con ng nghch san; benh nhan thng khong co nhiem Hp va khong co
viem da day man tnh. Ngoai ra, ngi ta cung ghi nhan co s tang nhe nguy c ung th loai
nay ngi nhom mau A.
Hnh thai ton thng:
- ai the: v tr ton thng cua carcinom da day c phan bo nh sau : 50-60% hang v
va mon v, 25% tam v, va phan con lai than v va ay v. B cong nho b ton thng trong
40% cac trng hp, nhieu hn so vi b cong ln, ch co 12%. Nh vay, v tr thng gap nhat
cua ton thng la b cong nho cua vung hang - mon v.
Da vao mc o xam nhap, phan biet ra 2 loai carcinom da day: (Hnh 19)
* Carcinom da day sm: ton thng con khu tru lp niem mac va di niem mac, bat ke
tnh trang a co hoac cha di can vao cac hach xung quanh da day.
* Carcinom da day tien trien: la trng hp ung th a xam nhap vao lp c hoac sau
hn na. Carcinom da day tien trien co 3 dang ai the cua: dang choi sui nho vao long
da day, chiem t le 40 -50%; dang tham nhiem, 26% va dang loet, 25%.
Hnh 19: Cac dang ai the cua carcinom tuyen da day
- Dang choi sui nho vao long da day, tao thanh mot khoi san sui nh nam hoac giong
polyp (polypoid).
- Dang tham nhiem nhn khong thay ro khoi u nhng co the thay s xoa mat cac nep gap
niem mac bnh thng tai vung nay. Khi ung th a tien trien, toan bo thanh da day co
the b xam nhap, tr nen day va cng, giong nh 1 cai chai bang da (linitis plastica).
- Dang loet, o loet co ng knh > 4cm, b o loet go cao va nham nh, ay o loet thng
co cha chat hoai t lui xui, niem mac quanh o loet xep nep theo hnh nan hoa. Tren
thc te, co mot so trng hp carcinom dang loet khong the phan biet c vi o lanh
tnh neu ch da vao ai the. (Hnh 20A)
- Vi the: nh a trnh bay tren, carcinom da day co 2 hnh thai mo hoc chnh la kieu ruot
va kieu lan toa.
* Kieu ruot gom nhng te bao ac tnh, sap xep thanh cau truc tuyen giong nh trong
carcinom tuyen ai trang (Hnh 20B).
* Kieu lan toa gom nhng te bao giong te bao tiet nhay trong tuyen da day; cac te bao
nay co hnh nhan, khong sap xep thanh tuyen, xam nhap vao trong tat ca cac lp cua thanh da
day di dang nhng te bao nam rai rac hoac tap trung thanh tng am nho (Hnh 20C).
Hnh 20: Carcinom da day tien trien dang loet, b go cao(A), Kieu ruot (B), Kieu lan toa, te bao nhan (C)
Cho du la kieu mo hoc nao th cac carcinom da day cuoi cung se vt qua lp thanh mac,
xam nhap vao cac c quan lan can nh ta trang, tuy tang; di can en cac hach quanh da day va
di can theo ng mau en gan va phoi. Carcinom da day co the cho di can sm en hach
thng on (hach Virchow). benh nhan n, carcinom da day co the di can vao phuc mac, en
ca hai buong trng tao nen u Krukenberg.
Lien he lam sang :

Carcinom giai oan sm thng khong co trieu chng va co the ch c kham pha qua
kham noi soi tam soat nh ky nhng vung co xuat o ung th da day cao (c ap dung
Nhat). Carcinom da day tien trien co the ch bieu hien bang vai trieu chng m ho nh cam giac
ay bung kho tieu, v.v. hoac ro ret hn nh au thng v, chan an, sut can, xuat huyet tieu
hoa, trieu chng hep mon v do khoi u chen ep.
Neu benh c phat hien trong giai oan carcinom da day sm, co kha nang cha khoi
bang phau thuat, t le song 5 nam at en 95-100%; khi benh a tien trien, t le nay ch con 10-
20%.
RUOT NON VA AI TRANG
ngi ln, ruot non dai khoang 6m va ruot gia (ai trang) khoang 1,5m. Ruot non gom 3
phan: ta trang, hong trang va hoi trang. ai trang gom 6 phan: manh trang, at trang len, ai
trang ngang, ai trang xuong va ai trang sigma va trc trang. Cau tao chung cua thanh ruot
gom 4 lp: niem mac, di niem mac, c va thanh mac.
Hai chc nang chnh cua ruot non la tieu hoa cac thc an bang hoat ong cua cac enzym
va hap thu cac chat dinh dng; chnh v vay, lp niem mac ruot non co rat nhieu nhung mao
(villi) e lam tang dien tch hap thu cua ruot. Ruot gia la ni tam tr chat can ba, gi vai tro quan
trong trong viec duy tr can bang nc ien giai cho c the
Nhieu loai nhiem khuan, viem va u, tac ong cung luc tren ca ai trang va ruot non; do
vay, benh ly cua 2 c quan nay c khao sat cung vi nhau.
I. D DANG BAM SINH
ruot non, co the gap 1 so d dang bam sinh sau:
1.Teo hoac hep: thng ch tac ong len mot oan ruot ; ruot b teo do qua trnh rong hoa
tao long trong thi ky phoi thai b nh tre hoac tuy co long nhng lai that hep.
2. Ruot che oi: thng co dang tui hoac boc-ong, co hoac khong thong noi vi long ruot
non.
3.Thoat v ron: la s thoat v ruot non ra ngoai o bung, do s suy yeu bam sinh cua thanh
bung quanh ron.
4. Tui tha Meckel: d dang thng gap
nhat, xay ra do ong mac treo - ron khong teo
lai, tao thanh 1 ong bt co chieu dai khoang 5-
6 cm, ng knh co the at gan bang kch
thc cua ruot non. Tui tha Meckel thng
thay hoi trang (trong khoang 85cm tnh t
manh trang), vach co cau tao 4 lp nh ruot
non bnh thng (Hnh 21)
Tui tha Meckel thng vo hai, khong
gay trieu chng. Trong mot so trng hp, tui
tha Meckel co cha mot o niem mac da day
lac cho, co the gay loet niem mac ruot ke can
a en xuat huyet tieu hoa. Mo tuy lac cho
Hnh 21 : Tui tha Meckel, dang ong bt nho.
tui tha Meckel cung co the gap nhng hiem
hn.
ai trang, co 2 d dang bam sinh chnh sau:

5. Quai ruot quay cha het trong thi ky phat trien phoi thai, khien cho cac oan ruot
khong c sap xep vao ung v tr bnh thng cua chung.Th du nh manh trang lai nam
goc tren phai hoac tren trai cua o bung. Loai d dang nay de dan en xoan ruot.
6. Benh phnh gian ai trang vo hach bam sinh (benh Hirschsprung):
Trong giai oan phoi thai, cac nguyen bao than kinh se di chuyen t mao than kinh en
thanh ruot gia e tao thanh am roi Auerbach trong lp c va am roi Meissner trong lp di
niem mac. Khi s di chuyen nay b c che, mot oan ruot vo hach se c hnh thanh va gay
tac ruot c nang; phan ai trang pha tren oan ruot vo hach se b phnh gian dan do ong
phan. Xuat o benh Hirschsprung vao khoang 1/5000 1/8000 tre sinh song, gii nam mac
benh nhieu hn n (t le 4:1).
Hnh 22: Phan ruot tren oan vo hach b phnh gian (A), thanh oan ruot vo hach co si than kinh (C)
nhng khong co te bao hach than kinh nh ngi bnh thng (B)
Hnh thai ton thng:
Tai oan ruot vo hach, khong tm thay te bao hach than kinh va am roi Auerbach trong
lp c cung nh am roi Meissner trong lp di niem mac; can nh la oan vo hach nay
khong b phnh gian. Hau het cac oan vo hach eu nam trc trang va ai trang sigma. Phan
ai trang pha tren oan vo hach, tuy co ay u te bao hach than kinh, lai b phnh to, co the
at en ng knh 15-20 cm; thanh ruot b mong dan do gian; oi khi thanh ruot co the day len
do lp c ph ai bu tr. Lp niem mac lot trong oan gian co the con nguyen ven hay b loet
nhe do co xat vi khoi phan co ac lai trong ruot. (Hnh 22)
Lien he lam sang: hau het cac trng hp eu c phat hien sm ngay sau sinh v
khong thay tre i phan xu va oi nhieu. Neu ch 1 oan ngan oan di trc trang b vo hach,
benh nhan van co the ai tien c khi co sc ran. Cac bien chng co the gap la viem ai trang
va thung ai trang. Benh can c chan oan phan biet vi viem loet ai trang sinh oc to hoac
benh nhiem ky sinh trung Trypanosoma.
II. BENH LY MACH MAU
1. Benh ruot thieu mau cuc bo (ischemic bowel disease):

Ton thng thieu mau co the gii han ruot non, ai trang hoac ca hai, tuy theo mach
mau nao b tac nghen. Tac nghen cap tnh mot trong ba ong mach chnh nuoi ruot (ong mach
mac treo trang tren, ong mach mac treo trang di, ong mach than tang) co the gay nhoi
mau nguyen mot oan ruot dai vai met; ngc lai, neu s tac nghen dien ra t t th co the
khong gay ra tac hai nao nh vao he thong thong noi rat phong phu gia cac mach mau tren.
Nhoi mau ruot do huyet khoi tnh mach mac treo tng oi t gap hn.
Phan biet 3 mc o nhoi mau ruot:.
- Nhoi mau niem mac (mucosal infarction): ton thng gii han trong lp niem mac.
- Nhoi mau thanh (mural infarction): ton thng gii han trong lp niem mac va lp di
niem mac.
- Nhoi mau xuyen thanh (transmural infarction): ton thng toan bo cac lp thanh ruot.
2 loai au thng do tac nghen 1 nhanh ong mach nho nam trong thanh ruot hoac do s
giam ti mau; loai nhoi mau xuyen thanh thng do tac cap tnh 1 nhanh ln cua ong mach
mac treo (Hnh 23).
Hnh 23: Ba mc o nhoi mau ruot
Cac yeu to thuan li lam benh ruot thieu mau cuc bo de xay ra:
+ Huyet khoi ong mach: x va ong mach mac treo, viem ong mach, phnh mach
tach, tai bien phau thuat.
+ Huyet tac ong mach: cuc huyet tac bong t not sui trong tim (viem noi tam mac, huyet
khoi vach tim) hoac t cac mang x va ong mach chu.
+ Huyet khoi tnh mach: tnh trang mau tang ong do uong thuoc nga thai, do b ung
th
+ Giam ti mau ong mach: suy tim, soc, mat nc, dung thuoc co mach (vasopressin).
Hnh 24: Nhoi mau ruot non do tac ong mach mac treo trang tren (A); Vi the cua mot nhoi mau niem
mac ruot non, niem mac xuat huyet, lp bieu mo bong troc, cac lp khac con nguyen ven (B)
Hnh thai ton thng:

- oan ruot b nhoi mau xuyen thanh co mau o bam, chieu dai thay oi tuy theo ong
mach nao b tac nghen. Ton thng do thieu mau nuoi xuat hien au tien tai lp niem mac roi
lan dan xuong cac lp ben di; en gi th 18, se co mot lp dch xuat t huyet phu len mat
ngoai lp thanh mac. Ve vi the, co the thay hien tng phu ne, xuat huyet, hoai t te bao va
bong troc niem mac. Thanh ruot hoai t co the b thung ngay trong ngay au tien do tac ong
cua cac vi khuan co san trong ruot. (Hnh 24)
- Trong nhoi mau thanh va nhoi mau niem mac, ton thng phan bo rai rac xen ke vi
nhng vung ruot bnh thng. Tai vung ton thng, niem mac phu ne, xuat huyet, b loet va co
gia mac phu ben tren. Hnh anh vi the gom co phu ne, xuat huyet, hoai t te bao. Phan ng
viem tai b ton thng tao ra dch xuat t huyet, tng ng vi gia mac thay c tren ai the.
Lien he lam sang: trieu chng cua nhoi mau xuyen thanh la mot cn au bung d doi,
xuat hien ot ngot, i kem vi tieu phan long lan mau. Benh nhan co the truy tim mach ch trong
vai gi. T le t vong do nhoi mau ruot xuyen thanh rat cao, co the len en 90%, co le do thi
gian t luc bat au co trieu chng lam sang en khi thung ruot qua ngan. Trieu chng cua nhoi
mau niem mac nhe nhang hn, benh nhan co the ch cam thay hi ay bung; cac ton thng co
the lanh han neu giai quyet c nguyen nhan gay thieu mau ruot.
2. Tr (hemorrhoids):
Tr la hien tng trng n cac tnh mach thuoc mang li di niem mac cua hau mon
va quanh hau mon, do s gia tang ap lc keo dai trong mang li tnh mach tr (hemorrhoidal
venous plexus). Thng gap nhng ngi tren 50 tuoi. Tr cung co the xuat hien nhng phu
n tre do s mau tnh mach trong luc mang thai. Cac yeu to thuan li khac dan en benh tr
gom co tnh trang tao bon man tnh, tang ap lc tnh mach ca do x gan.
Hnh thai ton thng:
- ai the: phan biet 3 loai tr:
* Tr noi, nam pha tren ng noi hau mon - trc trang, do s trng n mang li tnh
mach tr tren tao ra.
* Tr ngoai, nam pha di ng noi hau mon - trc trang, do s trng n mang li
tnh mach tr di tao ra.
* Tr hon hp, thng gap hn ca, c tao nen bi s ket hp ca 2 loai tr tren
- Vi the: cac tnh mach di niem mac trng n ngoan ngoeo, co thanh mong, lam cho
lp niem mac trc trang va niem mac hau mon b oi nho len. Phan nho ra nay de b nt, loet,
xuat huyet va boi nhiem do co xat vi phan.
III. TAC RUOT

Do cac nguyen nhan c hoc nh: long ruot, xoan ruot (thng gap tre nho). thoat v ruot
qua cac iem yeu cua vung bung (ben, ron), hoac cac nguyen nhan khac nh khoi u, x hep do
viem, dnh ruot sau mo. oan ruot b xoan, long hay thoat v co the b nhoi mau, hoai t hoac
thung gay viem phuc mac. (Hnh 25)
Hnh 25 : Bon nguyen nhan chnh gay tac ruot: thoat v, dnh ruot, long ruot, xoan ruot
IV. NHOM BENH LY VIEM

1. Viem ruot nhiem trung
La tnh trang viem ruot non hoac ai trang do cac tac nhan nh vi khuan, virut, ky sinh
trung.
- Benh viem ruot do vi khuan thng gay tieu chay, la nguyen nhan gay t vong cho hn
12.000 trng hp tre em moi ngay tai cac nc ang phat trien. Vi khuan vao ruot theo thc
an; co nhieu loai vi khuan gay benh khac nhau nh Clostridium botulinum, Staphylococcus
aureus, Salmonella, Shigella, Mycobacterium tuberculosis, Escherichia coli e gay viem ruot,
vi khuan phai co kha nang bam dnh hoac xam nhap vao trong te bao bieu mo niem mac ruot
hoac san xuat ra oc to oi vi ruot (enterotoxin).
Hnh thai va v tr ton thng thay oi khac nhau tuy loai vi khuan gay benh. Ton thng
ai the thng gap gom co tnh trang niem mac phu ne sung huyet o, co the co loet sau, ong
gia mac tham ch thung ruot (nh trong nhiem Salmonella typhi gay benh thng han). Trong
viem ruot do Mycobacterium tuberculosis, co s hnh thanh cac u hat lao trong lp niem mac.
Ve vi the, co the gap hnh anh viem cap tnh hoac man tnh niem mac ruot, cac te bao viem
tham nhap vao trong mo em va lp bieu mo be mat.
- Viem ruot do virut cung gay tieu chay. Cac loai virut gay benh thng gap la Rotavirus,
adenovirus, calicivirus, astrovirus va virut Norwalk.
- Cac ky sinh trung gay viem ruot thng gap la Entamoeba histolytica va Giardia lamblia.
Entamoeba histolytica chui vao long tuyen Lieberkhn cua ai trang, xam nhap va pha huy mo
em niem mac, tao ra cac o loet hnh chai thot co, ben trong cha chat hoai t mau nau socola.
Giardia lamblia th bam dnh va gay ton thng niem mac ruot non.
2. Benh viem ruot vo can (idiopathic inflammatory bowel disease):
Benh Crohn va benh viem loet ai trang la 2 benh tuy co hnh thai ton thng khac biet
nhng lai giong nhau cho eu gay ra tnh trang viem ruot man tnh, tai i tai lai ma nguyen
nhan th cha c biet; do o ngi ta goi chung 2 benh nay la benh viem ruot vo can (VRVC).
Ca 2 benh eu co them nhng ton thng viem nhieu c quan khac ngoai ruot va lam tang
nguy c ung th ruot.
C che benh sinh cua benh VRVC cho en nay van con ang trong vong nghien cu.
Ngi ta cho rang co s tac ong cua nhieu yeu to khac nhau trong c che phat sinh benh:
- Yeu to c a di truyen de mac benh: phan anh qua s xuat hien nhng trng hp
VRVC co tnh chat gia nh, 15% so benh nhan VRVC co them 1 thanh vien khac trong gia nh
cung mac benh. Nh vay, yeu to nay co the lien quan en mot so thay oi ve gen khien cho
ruot tr nen nhay cam, de b ton thng bi vi khuan, oc to hoac ap ng mien dch.
- Yeu to nhiem khuan: s nhiem cac vi khuan nh Chlamydia, Mycobacterium
paratuberculosis co the gi vai tro khi phat tnh trang viem man tnh; cac BCNTT, BCN ai
toan, limpho bao va ai thc bao c thu hut va hoat hoa, giai phong cac chat trung gian hoa
hoc gay ton thng niem mac ruot.
- Yeu to mien dch: hoat ong ieu hoa mien dch benh nhan VRVC b suy yeu do o
khong han che c tac ong co hai cua cac chat trung gian hoa hoc.
S phoi hp hoat ong gia cac yeu to tren khien phan ng viem c khi phat va duy
tr trong niem mac ruot, dan en tnh trang viem ruot man tnh.
Hnh 26 : So sanh cac dang ton thng va v tr ton thng cua benh Crohn (A) va viem loet ai trang (B)
a/ Benh Crohn:
Thng gap cac nc chau Au va chau My hn la cac nc chau A; xuat o benh
ngi da trang cao hn ngi da mau. Tai Viet nam, a co mot so trng hp benh Crohn c
ghi nhan. Benh co the xuat hien moi la tuoi nhng a so thng khi benh trong khoang tuoi
20-40.
Hnh thai ton thng:
- ai the: ton thng co the xuat hien bat ky oan nao cua ong tieu hoa, t thc quan
en hau mon, nhng hau het la ruot non va ai trang. Ton thng ch co ruot non trong 40%
trng hp, ch ai trang 30%, va ca ruot non va ai trang trong 30% trng hp.
oan ruot b viem co gii han rat ro vi oan bnh thng lan can; khi co nhieu oan ruot
cung b ton thng th chung c ngan cach nhau bang nhng oan ruot hoan toan bnh
thng. Thanh mac vung ton thng san sui dang hat mau xam, mat ngoai co the c bao bi
cac bm m mac treo. Thanh ruot day va dai, lam hep long ruot. Niem mac phu ne, co nhng o
loet nong phan bo rai rac. Cac o loet nay ve sau se hoa nhap lai theo truc doc cua ruot, tao
thanh nhng ranh loet doc (linear ulcer) va lam cho be mat niem mac ruot co hnh anh "a cuoi"
rat ac trng cho benh Crohn. Cac vet loet co the tiep tuc chui sau xuong qua cac lp cua
thanh ruot, lam cho cac quai ruot b dnh vao nhau hoac tao ra cac ng do thong noi gia ruot
vi cac c quan xung quanh (nh bang quang, am ao), hoac gay thung ruot va tao ra cac o ap
xe trong khoang phuc mac. (Hnh 26, 27)
- Vi the:
Cac bien oi mo hoc thay oi tuy theo thi iem quan sat.
Trong giai oan au co the thay hnh anh niem mac phu ne vi s tham nhap cua
BCNTT vao trong lp bieu mo va long cac tuyen ruot, tao thanh nhng o ap xe nho hoac
nhng o loet. Ve sau, co the thay cac ton thng niem mac man tnh nh xoa cac nhung mao
ruot non; cac tuyen Lieberkhn cua ruot gia b gian rong, meo mo hoac phan nhanh. Niem mac
ruot b teo dan, bieu mo be mat b chuyen san (chuyen san da day hoac chuyen san te bao
Paneth). Lp c niem, lp di niem mac va lp c day len, x hoa, gay cht hep long ruot.
Trong khoang 40-60% cac trng hp, co s hnh thanh cac u hat khong ba au hoa trong hoac
ngoai vung ruot b ton thng.
Hnh 27: Benh Crohn hoi trang, thanh ruot day, hep long ruot, niem mac hnh a cuoi va cac ranh loet
doc (mui ten), mat ngoai thanh mac co bm m mac treo bam (A); Tren vi the , niem mac tham
nhap te bao viem, co 2 o loet trong o mot o i sau en lp c (B).
Lien he lam sang: Benh nhan b nhng t sot, au bung, tieu chay hoac tieu ra mau xen
ke vi giai oan khong bieu hien trieu chng keo dai hang thang. Ve sau co the xuat hien them
cac trieu chng do bien chng tac ruot, do ruot - bang quang hoac ap xe trong khoang phuc
mac. Ngoai ra, co the thay trieu chng cua cac ton thng ngoai ruot nh viem a khp, hong
ban not, ngon tay dui trong. Nguy c ung th ruot gia tang t le thuan vi thi gian mac benh,
khoang 5% benh nhan se b ung th ruot sau khi benh a keo dai tren 7 nam. ieu tr bao gom
viec s dung cac thuoc khang viem, c che mien dch ket hp vi can thiep ngoai khoa e giai
quyet cac bien chng.
b. Viem loet ai trang (ulcerative colitis):
Tng t nh benh Crohn, benh viem loet ai trang thng gap cac nc Chau Au va
Chau My hn la cac nc chau A; xuat o benh ngi da trang cao hn ngi da mau.
Benh co the xuat hien moi la tuoi nhng a so thng khi benh trong khoang tuoi t 20-25
tuoi.
Hnh thai ton thng:
- ai the:
Khac vi benh Crohn, ton thng trong viem loet ai trang khi au trc trang roi lan
ngc len dan mot cach lien tuc, co khi toan bo khung ai trang; khong co nhng oan ruot
lanh chen gia. Niem mac vung ton thng sung huyet o, de b bong troc tao thanh nhng o
loet rong. Tren nen loet xuat huyet, co the thay hoat ong tai tao cua niem mac tao nen nhng
not choi len giong nh polyp. Thanh ruot khong day len va be mat thanh mac hoan toan bnh
thng. (Hnh 28)
- Vi the:
Cac bien oi mo hoc tng t nh trong benh Crohn, ch khac mot so iem sau:
+ Khong co hnh thanh u hat trong thanh ruot.
+ Cac vet loet niem mac ch lan xuong di niem mac, khong pha huy lp c.
+ Khi benh vao giai oan thuyen giam, vet loet se c lap ay bang mo hat viem va
hoa seo, lp niem mac ben tren lai c tai tao.
Hnh 28: Niem mac cua viem loet at trang sung huyet, co nhng not choi giong polyp (A); Tren vi
the,niem mac tham nhap te bao viem, hoa si trong lp di niem mac, lp c bnh thng (B).
Lien he lam sang: benh bieu hien bang nhng t i tieu phan long co lan am mau keo
dai hang thang sau o giam dan va roi lai tai phat. Nguy c ung th ruot gia tang t le thuan vi
thi gian mac benh, khoang 11% benh nhan se b ung th ruot sau khi benh a keo dai tren 10
nam. ieu tr chu yeu bang noi khoa vi cac thuoc khang viem va thuoc c che mien dch.
V. U VA TON THNG GIA U

Mac du ruot non chiem 3/4 chieu dai ong tieu hoa nhng u ruot non ch chiem 3-6% u
ng tieu hoa, phan ln la u lanh nh u tuyen, u c trn. U ac ruot non tng oi hiem gap,
gom cac loai nh carcinom tuyen, u carcinoid, lymphom va sarcom.
ai trang co nhieu u hn bat ky c quan nao khac trong c the. So lieu cua Viet nam
(2004-08) cho thay ung th ai - trc trang ng hang th 3 va 4 oi vi gii nam va n thanh
pho Ho ch Minh. ng hang th 4 va 2 oi vi gii nam va n cua thanh pho Ha noi. a so ung
th ai - trc trang la carcinom tuyen, chiem 70% u ac ng tieu hoa.
Phan loai u cua ruot non va ai trang giong nhau, gom co cac loai chnh sau ay:
- Polyp gia u (non neoplastic polyp):

+ Polyp tang san (hyperplastic polyp).
+ Polyp hamartom (hamartomatous polyp):
* Polyp tuoi tre (juvenile polyp).
* Polyp Peutz - Jeghers.
- U xuat phat t bieu mo (neoplastic epithelial lesions):
+ U lanh: u tuyen (adenoma).
+ U ac: carcinom tuyen, u carcinoid.
- U xuat phat t trung mo (mesenchymal lesions):
+ U mo em ong da day - ruot (gastrointestinal stromal tumors).
+ Cac loai u lanh khac: u m, u than kinh, u mach mau.
- Limphom
1. Polyp gia u
Xuat hien chu yeu ai trang va la loai polyp thng gap nhat, chiem 90% polyp ai
trang. Xuat o gia tang theo tuoi tac; no c tm thay hn phan na so ngi tren 60 tuoi.
a/ Polyp tang san: hau het polyp gia u thuoc ve loai nay, polyp co kch thc nho (< 5
mm ng knh), be mat trn lang. Polyp tang san co the xuat hien n oc hoac nhieu cai
cung luc; hn phan na so trng hp co v tr vung ai trang sigma - trc trang. Ve vi the,
cac polyp nay cha nhieu tuyen co cau truc giong tuyen bnh thng vi cac te bao hnh ai va
te bao hap thu. (Hnh 29)
Hnh 29: Poyp tang san co kch thc nho (A); vi the co cau truc tuyen giong bnh thng (B)
b/ Polyp tuoi tre: ay la mot hamartom cua lp niem mac, co dang polyp, xuat hien chu
yeu tre nho di 5 tuoi. Polyp thng thay trc trang, co kch thc kha ln (1-3 cm ng
knh), thng co cuong, be mat lang hoac co the hi b sung huyet va loet trt. Ve vi the, polyp
cau tao bi mo em tham nhap te bao viem, bao quanh cac tuyen gian rong.
c/ Polyp Peutz - Jeghers : cung la mot hamartom dang polyp, xay ra nhng ngi b
hoi chng Peutz - Jeghers. Polyp co kch thc ln va co cuong, xuat hien n oc hoac nhieu
cai cung luc, phan bo rai rac doc ong tieu hoa. Ve vi the, polyp c cau tao bi mot loi si
collagen va c trn phan nhanh, bao quanh cac tuyen c lot bi bieu mo ruot co cha nhieu
te bao hnh ai. Polyp Peutz - Jeghers khong co tiem nang ac tnh nhng nhng ngi b hoi
chng Peutz - Jeghers, co s gia tang nguy c carcinom tuyen tuy, vu, phoi, buong trng va
t cung.
2. U tuyen (adenoma):
U tuyen thng co dang polyp nen con c goi la polyp tuyen (adenomatous polyp). U
tuyen xuat hien chu yeu ai trang vi xuat o tang dan theo tuoi tac, t 20% ngi di 40
tuoi, tang len en 50% ngi tren 60 tuoi; gii nam va gii n mac benh nh nhau (t le 1:1).
Tuy theo ac iem cau truc cua thanh phan bieu mo, phan biet 3 loai polyp tuyen:
- U tuyen ong (tubular adenoma): la loai thng gap nhat, chiem t le 90%.
- U tuyen nhanh (villous adenoma): chiem t le 1%.
- U tuyen ong - nhanh: hon hp cua 2 loai tren, chiem 5-10%.
S hnh thanh u tuyen la ket qua hoat ong tang san kem nghch san cua bieu mo ruot;
nghch san co the xay ra moi mc o, t nhe en nang va co the tm thay ca nhng o
carcinom tai cho. V vay, co the xem u tuyen la 1 ton thng tien ung. Nguy c hoa ac cua u
tuyen tuy thuoc vao 3 yeu to sau:
+ Kch thc u tuyen: kch thc cang ln th nguy c cang tang.
+ Loai u tuyen: u tuyen nhanh co nguy c hoa ac cao hn u tuyen ong.
+ Mc o nghch san: nghch san cang nang, nguy c cang cao.
Nh vay, ton thng ang lo ngai nhat chnh la cac u tuyen nhanh co kch thc ln hn
4cm va co kem hien tng nghch san nang.
Hnh thai ton thng:
a/ U tuyen ong:
Xuat hien chu yeu ai trang, n oc hoac nhieu cai cung luc. U tuyen ong thng co
kch thc nho (t khi > 2,5cm) be mat tng oi lang va co cuong. Ve vi the, cuong polyp c
phu bi lp niem mac ai trang bnh thng, ben trong la mo em si lien ket - mach mau xuat
phat t lp di niem mac. Phan au polyp c tao bi bieu mo ruot tang san va nghch san,
tao thanh cac ong tuyen meo mo sap xep chen chuc vi nhau, te bao tuyen co nhan tang sac.
Canh nhng vung nghch san nang, co the tm thay nhng o carcinom con giai oan tai cho
hoac a xam nhap vao lp di niem mac trong cuong polyp. (Hnh 30)
Hnh 30: U tuyen ong co cuong (A, B), ben canh cac tuyen tang san lanh tnh, co vung nghch san nhe (C) .
b/ U tuyen nhanh:
Xuat hien chu yeu trc trang va ai trang sigma. U tuyen nhanh thng co kch thc
ln (co the at en 10cm), san sui nh bong cai va khong co cuong. Ve vi the, u tuyen nhanh
tao bi bieu mo ruot tang san va nghch san, tao thanh cac cau truc dang nhanh giong nhung
mao ruot. Tai ay, co the tm thay ton thng nghch san moi mc o va ca nhng o carcinom
con trong giai oan tai cho hoac a xam nhap thang vao trong lp di niem mac cua thanh
ruot (v loai nay khong co cuong nh u tuyen ong). (Hnh 31)
Hnh 31: U tuyen nhanh khong cuong (A,B), canh cac tuyen tang san lanh tnh, co vung nghch san nhe (C).
c/ U tuyen ong - nhanh:

La dang hon hp cua 2 loai tren. U co kch thc thay oi, co the co cuong hoac khong co
cuong. Ve vi the, u c tao bi bieu mo ruot tang san va nghch san, tao thanh cac ong tuyen
va cac nhanh, vi thanh phan nhanh chiem t le vao khoang t 25-50% .
Lien he lam sang: U tuyen thng khong co bieu hien trieu chng, v vay can phai co
chng trnh tam soat e phat hien va cat bo trc khi u chuyen thanh ung th.
3. Benh polyp tuyen gia nh (familial adenomatous polyposis):

Benh t gap, di truyen tren kieu
gen troi - nhiem sac the thng.
Benh bieu hien vi s xuat hien ngay
t tuoi tre hang tram polyp tuyen
ai trang (a so thuoc loai u tuyen
ong); hau nh chac chan se co s
chuyen dang ac tnh cua 1 trong cac
polyp nay thanh ung th ai trang khi
benh nhan bc vao tuoi trung nien.
(Hnh 32)
Hoi chng Gardner la mot bien
the cua benh polyp tuyen gia nh noi
tren, cung co kieu di truyen gen troi -
nhiem sac the thng. Benh nhan co
cac polyp tuyen ai trang i kem
Hnh 32: Benh polyp tuyen gia nh, niem mac co vo so polyp
vi u xng nhieu ni (xng so,
xng ui, xng canh tay).
Hoi chng Turcot la mot bien the khac vi s xuat hien cua cac polyp tuyen ai trang i
kem vi u than kinh trung ng; benh cung c di truyen theo gen troi - nhiem sac the thng.
Cac benh nhan mac phai 2 hoi chng tren eu co nguy c b ung th ai trang do s chuyen
dang ac tnh cua 1 trong cac polyp tuyen ai trang.
4. Carcinom tuyen ai - trc trang
98% cac ung th ai trc trang thuoc ve loai carcinom tuyen, u carcinoid ch chiem 2%; v
vay khi noi en ung th ai trc trang th co the ngh ngay en loai carcinom nay.
Dch te hoc: a so benh nhan la nhng ngi ln tuoi, trong khoang t 60-70 tuoi; ch co 20%
trng hp xuat hien trc 50 tuoi. Nam b nhieu hn n (t le 5:4). So lieu cua Viet nam (2004-
2008) cho thay ung th ai trc trang ng hang th 3 va 4 oi vi gii nam va n cua thanh
pho Ho ch Minh; hang th 4 va 2 oi vi gii nam va n thanh pho Ha noi. Nguyen nhan gay
benh cha c biet ro nhng nhng yeu to sau ay c cho la lam tang nguy c mac benh:
- Ton thng co trc tai ruot:
+ U tuyen: la ton thng tien ung cua carcinom tuyen ai-trc trang, nhat la nhng u
tuyen co kch thc ln va co dang nhanh.
+ Benh polyp tuyen gia nh, hoi chng Garner, hoi chng Turcot.
+ Benh Crohn, benh viem loet ai trang.
- Yeu to moi trng: che o an nhieu tht m nhng lai t rau qua va chat x co the tao
thuan li cho s phat sinh ung th.
Hnh thai ton thng:
- ai the: v tr cua ung th c phan bo nh sau:
+ Manh trang va ai trang len: chiem 38% cac trng hp.
+ ai trang ngang: 18%.
+ ai trang xuong: 8%.
+ ai trang sigma va trc trang: 36%.
Ton thng ai trang phai thng co dang choi sui hoac giong polyp, nho vao trong
long ruot; ton thng ai trang trai thng co dang loet va tham nhiem, lan vong theo chu vi
cua ruot. ca 2 dang tren, khi ung th tien trien se xam nhap qua tat ca cac lp cua thanh ruot,
lam day cng thanh ruot, nhan nhum thanh mac va cht hep long ruot.
- Vi the: Tuy theo mc o biet hoa, cac te bao ung th co the tao thanh nhng cau truc
tuyen co long ong ro ret hoac ch tap hp thanh cac am ac; s xam nhap cua te bao ung th
thng kch thch mot phan ng tang sinh si rat manh. (Hnh 33)
Lien he lam sang: ung th ai - trc trang thng dien tien am tham trong nhieu nam nen
khi phat hien th a vao giai oan muon; ung th ai trang trai co the c phat hien sm
hn nh vao cac trieu chng nh au vung ho chau trai, tieu am khien benh nhan phai i noi
soi. giai oan muon, ung th ai - trc trang thng xam nhap cac cau truc lan can, di can
vao xoang phuc mac, di can theo mach bach huyet en cac hach vung hoac di can xa theo
ng mau en gan, phoi va xng.
Hnh 33: Carcinom tuyen ai trang xuong, dang sui loet; cac mui ten ch v tr cac polyp (A); vi the cua
carcimom tuyen biet hoa cao, xam nhap lp c (B)
e anh gia tien lng cua benh nhan, co the tien hanh xep giai oan benh theo bang
phan loai cua Dukes (Hnh 34) :
+ Giai oan A: ung th cha xam nhap qua lp c.
+ Giai oan B: ung th a xam nhap qua lp c, cha di can hach.
+ Giai oan C: ung th xam nhap het thanh ruot kem di can hach.
+ Giai oan D: a co di can xa.
Hnh 34: Giai oan lam sang theo Dukes

Neu nh sau phau thuat, tren 90% benh nhan giai oan A co kha nang song them 5
nam th t le nay giam xuong con 55-70%, 20-40% va di 10% oi vi benh nhan giai oan
B, C va D.
RUOT THA
1. Viem ruot tha cap
* Dch te hoc: thng gap tuoi thanh nien; nam b nhieu hn n ( t le 1,5:1).
* Benh sinh: a so cac trng hp viem ruot tha co lien quan vi tnh trang tac nghen
long ruot do cuc phan, bui giun.
Hnh thai ton thng:
- ai the:
Giai oan sm: ruot tha cang to, thanh mac
sung huyet, co phu gia mac. (Hnh 35)
Giai oan muon: viem mu ruot tha, ruot tha
co the b loet thung gay viem phuc mac.
- Vi the:
Giai oan sm: tham nhap BCNTT trong
lp niem mac, lp di niem mac va lp c. Mach
mau di thanh mac sung huyet, ay hong cau.
Giai oan muon: niem mac b loet, long ruot
co dch xuat mu, co o ap-xe va hoai t trong thanh
ruot, tren be mat thanh mac co dch xuat t huyet. H.35: Ruot tha viem sung huyet, co gia
mac. Trong long ruot tha co cuc phan to.
2. U ruot tha
U ruot tha noi chung hiem gap, thng c phat hien tnh c trong khi mo cat ruot tha.
Cac loai u ruot tha co the gap gom co u tuyen nhay, carcinom tuyen (eu co dang u nhay tren
ai the) (Hnh 36), u carcinoid va limphom.
Hnh 36: Ruot tha dan rong do u tuyen nhay (A), chat nhay chay ra khi xe ruot tha (B), cau tao vi the cac
tuyen tiet nhay (C).
1. Ve thc quan Barrett, phat bieu sau KHONG UNG:

A/ La bien chng cua viem thc quan trao ngc keo dai
B/ Niem mac thc quan vung ton thng co mau o mt
C/ Co hien tng chuyen san bieu mo lat tang khong sng hoa thanh bieu mo tru n tiet
nhay
D/ Bieu mo tru chuyen san co the b nghch san t nhe en nang
E/ Tang nguy c b carcinom te bao gai thc quan
2. Mot benh nhan nam 60 tuoi ot ngot non oi ra rat nhieu mau o ti; benh nhan co HBsAg
dng tnh va trc ay khong co nhng t oi mau nh vay. Tnh trang oi mau nay nhieu kha
nang nhat la do benh ly thc quan sau:
A/ Trng n tnh mach thc quan B/ Thc quan Barrett C/ Viem thc quan trao ngc
D/ Viem thc quan do nam E/ Carcinom te bao gai
3. Hnh anh nghch san co the thay trong:

A/ Thc quan Barrett B/ Viem thc quan do trao ngc dch v
C/ Viem da day man D/ A & C ung E/ A & B ung
4. Vi khuan Helicobacter pylori co the gay ra:

A/ Loet da day-ta trang man tnh B/ Carcinom tuyen da day
C/ Limphom da day D/ Ch B va C ung E/ Tat ca A, B, C ung
5. Viem da day man tnh thng kem theo:

A/ Teo niem mac tuyen B/ Nghch san bieu mo tuyen C/ Nhiem H.pylori
D/ A & B ung E/ A, B, C ung
6. O loet da day ta trang:

A/ Co 4 lp B/ Lp di cung co hien tng x hoa
C/ Lp tren cung co nhieu BC a nhan trung tnh
D/ Ch A va B ung E/ Tat ca A,B,C ung
7. C che bao ve niem mac da day-ta trang chong lai loet man tnh bao gom cac yeu to sau,
NGOAI TR:
A/ S tiet nhay cua te bao bieu mo be mat
B/ Kha nang tang sinh tai tao cua te bao bieu mo be mat
C/ He thong ti mau niem mac phong phu
D/ S tang tiet gastrin
D/ Cac te bao bieu mo be mat che tiet bicarbonat natri vao trong lp chat nhay
8. Carcinom da day tien trien kieu ruot co hnh anh mo hoc:

A/ Cac te bao ac tnh xep dang tuyen nam lp niem mac
B/ Cac te bao ac tnh xep dang tuyen nam lp c
C/ Cac te bao ac tnh co hnh nhan nam lp niem mac
D/ Cac te bao ac tnh co hnh nhan nam lp c
E/ Tat ca A,B,C,D sai
9. Tnh chat nao sau ay gap trong o loet ung th cua da day :
A/ O loet thng ch tam v B/ ay o loet co nhieu BC ai toan
C/ B o loet go cao D/ A va C ung
E/ A, B, C ung
10. Polyp nao sau ay co kha nang hoa ac nhieu nhat:

A/ Polyp do viem ai trang B/ Polyp tang san
C/ Polyp thanh thieu nien D/ Polyp Peutz - Jeghers E/ Polyp u tuyen nhanh
11. Mot phu n trung nien, ot ngot len cn au bung d doi, i kem vi tieu phan long lan mau.
Benh nhan co tien can cao huyet ap va x va ong mach. Cn au bung cap nay co nhieu kha
nang nhat la do:
A/ Viem ruot hoai t do Clostridium perfringens
B/ Nhoi mau ruot C/ Lao hoi - manh trang
D/ Long ruot E/ Tr
12. KHONG lien quan en yeu to nguy c cua carcinom tuyen ai trang:
A/ Viem loet ai trang man tnh
B/ U tuyen nhanh kch thc ln
C/ Benh a polyp tuyen gia nh
D/ Dung thuoc khang viem khong corticoid
E/ Che o an nhieu tht m va t x
13. Carcinom tuyen ai trang:

A/ Thng b tuoi thanh thieu nien
B/ Lien quan che o an nhieu m
C/ Ve ai the thng co dang sui,loet hoac tham nhiem
D/ Co the xuat phat t polyp tang san kch thc nho
E/ Ve vi the thng co dang te bao nhan, lan toa.
14. Sinh thiet oan ai trang ngay di oan ruot phnh dan trong benh Hirschsprung:
A/ Khong tm thay te bao hach than kinh trng thanh trong am roi Auerbach
B/ Co te bao hach than kinh trng thanh trong am roi Meissner
C/ Thng kem viem loet ai trang
D/ Co ton thng viem hat kem theo
Benh ly Gan 189
BENH LY GAN
Muc tieu:
1. Neu ten va mot so ac iem chnh cua cac loai virut viem gan.
2. Neu ac iem lam sang - giai phau benh cua 5 the benh viem gan sieu vi.
3. Mo ta cac dang ton thng gan do ru.
4. Mo ta hnh thai ton thng gan do mat
5. Neu c che benh sinh cua x gan.
6. Ke ten cac loai u lanh va ac thng gap gan.
M AU
ngi ln, gan nam vung ha sn phai trong khoang bung, nang khoang 1,2-1,5kg;
gom 2 thuy, thuy phai ln hn thuy trai.
Hnh 1: He thong ng mat va mach mau gan
Gan nhan mau t 2 nguon :

- Mau ong mach t ong mach gan phai va trai, la nhanh cua ong mach chu.
- Mau tnh mach t tnh mach ca, dan mau t ong tieu hoa (da day - trc trang) va lach.
Mau ri khoi gan qua tnh mach tren gan, o vao tnh mach chu di. Mat tao gan va
c dan vao ong gan phai va ong gan trai; 2 ong nay nhap lai thanh ong mat chung o vao tui
mat, ni d tr va co ac mat, cuoi cung mat c o vao ong mat chu khi co hoat ong tieu
hoa. (Hnh 1)
Khoang ca cha nhanh cua ong mat, ong mach gan, tnh mach ca, tao thanh bo ba
khoang ca va c nang bi mo lien ket giau collagen.
n v cua gan, theo quan iem cau truc la cac tieu thuy gan (lobule); hoac theo quan
iem cau truc - chc nang la cac tui tuyen (acini).
- Tieu thuy: trung tam la tnh mach trung tam tieu thuy, ngoai vi c gii han bi ng
noi gia cac khoang ca.
- Tui tuyen: trung tam la bo 3 khoang ca, ngoai vi gii han bi tnh mach trung tam tieu
thuy. (Hnh 2)
So vi n v tieu thuy, n v tui tuyen giai thch tot hn cac roi loan sinh ly benh trong
benh gan; th du vung te bao gan vung 3 (trung tam tieu thuy) la vung nhay cam nhat vi tnh
trang thieu oxy do cac roi loan tuan hoan nh truy tim mach.
Nam tai v tr giao lo gia ng tieu hoa va phan con lai cua c the; gan co nhiem vu duy
tr s can bang chuyen hoa cho c the bang nhieu hoat ong khac nhau nh che bien cac acid
amin, ng, lipid va vitamin; tong hp cac protein huyet tng; kh oc va bai xuat vao mat
cac chat can ba noi sinh va chat oc ngoai sinh. Do vay, gan de b thng ton bi hang loat tac
Benh ly Gan 190
nhan khac nhau nh cac chat oc, dc pham, san pham chuyen hoa, vi sinh vat, roi loan
tuan hoan. Cac ton thng nay co the nguyen phat tai gan, hoac th phat do cac benh ly ngoai
gan nh suy tim mat bu, tieu ng, nhiem khuan ngoai gan. Nh co kha nang d tr rat ln,
hoat ong tai tao te bao gan luon xay ra sau moi ton thng, ngoai tr cac trng hp ton
thng qua nang; tuy nhien hoat ong tai tao ch hu hieu khi khung lien ket mach mau cua mo
gan con nguyen ven. mot ngi khoe manh, co the cat bo 60% gan ma van khong gay ra suy
chc nang gan va ch sau 4-6 tuan, khoi lng gan lai c phuc hoi nh cu nh hoat ong tang
san bu tr.
Hnh 2 : n v tieu thuy va n v tui tuyen (A), Mo hnh 3 chieu cua tieu thuy gan (B)
Benh ly gan rat a dang va phong phu; nhng tai Viet nam, viem gan sieu vi man tnh va
viem gan do ru van la 2 loai benh ly thng gap nhat, i kem vi chung la ton thng x gan
va ung th gan
I. VIEM GAN SIEU VI

Viem gan co the xay ra trong cac benh nhiem khuan virut toan than nh benh bach cau
n nhan nhiem khuan do virut Epstein-Barr, benh nhiem Cytomegalovirus, benh sot vang do
Arbovirus B. tre em va ngi suy giam mien dch, viem gan con co the xay ra trong benh si,
benh nhiem Adenovirus, virut Herpes va Enterovirus. Mac du viem gan co the do nhieu loai
virut khac nhau gay ra, nhng thuat ng viem gan sieu vi hau nh ch danh rieng cho viem gan
gay ra bi 1 nhom nho cac virut co ai tnh ac biet vi te bao gan la cac virut viem gan A, B,C,
D va E.
ac iem lam sang - giai phau benh cua cac viem gan sieu vi tng oi giong nhau, do
o can co cac xet nghiem huyet thanh hoc e phan biet gia cac loai virus gay viem gan va e
anh gia dien tien benh. Hnh thai ton thng chung cua viem gan sieu vi se c trnh bay sau
phan gii thieu ngan ve tng loai virut.
A. Cac loai virut viem gan

1. Virut viem gan A (HAV - hepatitis A virus):
HAV la virut cha chuoi ARN n, thuoc ho picornavirus. HAV khong gay ra viem gan
man tnh cung nh tnh trang ngi lanh mang mam benh (carrier state). Viem gan A (hepatitis
A) la mot benh co dien tien lanh tnh, t gii han, benh canh lam sang thng nhe hoac khong
co trieu chng; t le t vong do HAV rat thap, ch vao khoang 0,1%. HAV lay truyen qua ng
Benh ly Gan 191
phan - mieng (fecal - oral route), nhng t
bung dch ln co the do thc an va nc
uong b nhiem virut t phan ngi benh.
Thi gian u benh kha ngan, t 2 en 6
tuan; HAV co trong phan benh nhan 1-2
tuan trc khi benh khi phat va tiep tuc
ton tai 1 tuan sau o; bien mat khi chuan
o IgM khang HAV tang len. Chan oan
xac nh khi tm thay IgM khang HAV, bang
chng cua tnh trang nhiem virut cap tnh.
ap ng IgM bat au sut giam sau vai
thang nhng IgG khang HAV se xuat hien,
ton tai nhieu nam hoac suot i, bao ve c
the khoi b tai nhiem HAV. HAV gay ton
thng te bao gan bi tac ong gay oc
trc tiep len te bao. (Hnh 3) H.3: S thay oi chuan o khang the trong viem gan A
2. Virut viem gan B (HBV - hepatitis B virus):

HBV la virut cha chuoi ADN kep, thuoc ho hepadnavirus. HBV co the gay ra viem gan
cap tnh, viem gan man tnh tien trien en x gan va viem gan toi cap vi tnh trang hoai t gan
toan bo. HBV lay truyen chu yeu qua ng mau va cac dch c the, nhng virut cung co mat
trong tinh dch, nc bot, nc mat, sa; do o viec truyen mau, loc mau ngoai than, chch ma
tuy, ong tnh luyen ai, giao hp, sanh e, eu co nguy c lay nhiem HBV. Sau thi gian u benh
kha dai t 4-26 tuan, benh nhan co cac trieu chng cua viem gan cap tnh nh sot, vang da
trong nhieu tuan en nhieu thang; a so se i vao thi ky lui benh vi s bien mat cua virut; so
khac tr thanh ngi lanh mang mam benh, viem gan man tnh co hoac khong tien trien thanh
x gan. Chan oan xac nh khi tm thay khang nguyen be mat cua HBV (HBsAg), HBsAg xuat
hien trc khi co trieu chng lam sang cua viem gan, tang en cc ai roi giam dan va biem
mat sau 3-6 thang. S hien dien khang nguyen e cua HBV (HBeAg) va ADN cua HBV trong
huyet thanh benh nhan chng to HBV ang hoat ong sinh san. Khang the IgM khang HBc xuat
hien ngay trc khi co trieu chng cua viem gan, ton tai nhieu thang va sau o c thay bang
IgG khang HBc. Khang the khang HBe ch xuat hien sau khi khang nguyen HBeAg bien mat,
chng to benh ang lui dan. Khang the IgG khang HBs ch xuat hien khi a qua giai oan viem
cap tnh va HBsAg a bien mat; khang the nay co the ton tai suot i, bao ve c the khoi tai
nhiem HBV. Trai lai, neu khang nguyen HbsAg va HBeAg van tiep tuc ton tai th coi nh viem
gan B a chuyen sang man tnh vi ton thng gan tiep tuc tien trien. Tnh trang ngi lanh
mang mam benh c xac nh khi co s hien dien cua HBsAg tren 6 thang. (Hnh 4)
Hnh. 4 : S thay oi chuan o khang the trong viem gan B cap (A) va man (B).
Benh ly Gan 192
Virus gay ton thng te bao gan khong do tac ong gay oc trc tiep, nhng bang
cach trnh dien cac khang nguyen HBsAg len be mat te bao gan, qua o kch hoat ap ng
mien dch cua c the dan en pha huy te bao gan b nhiem virut. Neu he mien dch cua c the
b suy yeu hoac co s dung nap khang nguyen, virut co the song trong te bao gan ma khong
gay ton thng, benh nhan tr thanh ngi lanh mang mam benh. e phong nga viem gan B,
can tien hanh chch nga.
3. Virut viem gan C (HCV-Hepatitis C virus):
HCV la virut cha chuoi ARN n, thuoc ho Flaviviridae. HCV lay truyen qua ng mau,
do o nguy c lay nhiem cung tng t HBV. Viem gan C co thi gian u benh tng oi ngan, t
2-26 tuan. ARN cua HCV c tm thay trong mau trong khoang 1-3 tuan, trung hp vi giai
oan transaminase huyet thanh tang cao. Viem gan C cap tnh thng dien tien nhe nhang, t
trieu chng va trong huyet thanh co khang the khang HCV. Tuy nhien, 50% trng hp nhiem
HCV se tr thanh viem gan man tnh, phan na so nay tien trien dan en x gan sau 5-20 nam;
cac benh nhan nay, luon tm thay ARN cua HCV trong mau. ieu ang buon la en nay van
cha co vac xin phong nga viem gan C (Hnh 5).
Hnh 5 : S thay oi chuan o khang the trong viem gan C cap (A) va man (B).
4. Virut viem gan D (HDV - hepatitis D virus):

HDV la 1 virut khiem khuyet cha chuoi ARN n, lay truyen qua ng mau nhng phai
co mat HBV. Thi gian u benh ngan t 4-7 tuan; nhiem HDV cung luc vi HBV co the gay ra
viem gan t the nhe en the rat nang; nhiem HDV tren ngi a co san HBV se lam tnh trang
viem gan B nang ne hn, mau chuyen sang the man tnh hn. Xet nghiem huyet thanh hoc cho
thay ARN cua HDV va khang nguyen HDVAg xuat hien ngay trc khi co bieu hien trieu chng.
S hien dien cua khang the IgM khang HDV la bang chng a co nhiem HDV gan ay.
5. Virut viem gan E (HEV- hepatitis E virus):

HEV la virus cha chuoi ARN n, lay nhiem qua ng tieu hoa va co the phat trien
thanh dch. HEV gay ra viem gan cap, thi gian u benh t 2-8 tuan, dien tien benh thng lanh
tnh, khoi sau 2-4 tuan. HEV khong gay ra viem gan man tnh cung nh tnh trang ngi lanh
mang mam benh (carrier state). Xet nghiem huyet thanh hoc cho thay khang the IgM khang
HEV xuat hien cung luc vi cac trieu chng lam sang cua viem gan.
Bang tom tat cac ac iem chnh cua virut viem gan
HAV HBV HCV HDV HEV

Cau tao di truyen ARN n ADN kep ARN n ARN n ARN n
Lay truyen Phan - mieng Mau Mau Mau Tieu hoa
Giai oan u benh 2-6 tuan 4-26 tuan 2-26 tuan 4-7 tuan 2-8 tuan
Ng.lanh mang virut Khong Co Co Co Khong
Viem gan man Khong Co Co Co Khong
Ung th gan Khong Co Co Khong Khong ro
Benh ly Gan 193
B. ac iem lam sang - giai phau benh cua viem gan sieu vi
Sau khi nhiem virut viem gan, co the gap cac the benh sau:
- Tnh trang ngi lanh mang benh.
- Viem gan khong trieu chng, ch co bang chng huyet thanh hoc.
- Viem gan sieu vi cap tnh, co hoac khong co trieu chng vang da.
- Viem gan sieu vi man tnh: co hoac khong co tien trien thanh x gan.
- Viem gan sieu vi toi cap, t hoai t tieu thuy en hoai t gan toan bo.
1. Tnh trang ngi lanh mang benh

La tnh trang ngi mang virut
nhng khong co bieu hien trieu chng,
v vay tr thanh mot nguon lay trong
cong ong. Tnh trang nay rat thng
gap oi vi HBV va HCV, nhng khong
co oi vi HAV va HEV.
Hnh thai ton thng: ngi
lanh mang HBV, mau sinh thiet gan co
ve bnh thng; co the tm thay 1 so
am te bao gan co bao tng dang hat
mn, ai toan, goi te bao gan dang "knh
m" (do cha qua nhieu HBsAg trong
bao tng). (Hnh 6) Hnh 6: Te bao gan dang "knh m"
2. Viem gan sieu vi khong trieu chng, thng c phat hien tnh c do th mau thay
transaminase tang cao, kiem tra bang cac xet nghiem th thay co khang the khang virut viem
gan.
Hnh 7: S khac biet gia viem gan sieu vi cap va viem gan sieu vi man tnh
3. Viem gan sieu vi cap tnh

Bat ky virut viem gan nao cung co the gay ra viem gan sieu vi cap tnh, dien tien qua 4
giai oan:
- Giai oan u benh: khac nhau tuy loai virut viem gan.
Benh ly Gan 194
- Giai oan tien vang da (preicteric phase): benh nhan co cac trieu chng c nang
khong ac hieu nh cam giac kho , met moi, an kem ngon, sot nhe, au nhc khap ngi...
- Giai oan vang da: cac trieu chng c nang tren bat au bien mat, benh nhan thay khoe
hn nhng lai thay xuat hien vang da vang mat, nc tieu xam mau do bibirubin trc tiep trong
mau tang cao, phan co the hi lat mau do mat. Giai oan nay co the keo dai vai tuan en vai
thang.
- Giai oan hoi phuc: vang da va cac trieu chng khac giam dan.
Hnh thai ton thng:
- ai the: gan hi ln.
- Vi the: co the thay cac hnh anh ton thng sau (Hnh 8):
+ Te bao gan b thoai hoa nc phong to, bao tng nhat mau.
+ Te bao gan mat, cha sac to mat trong bao tng, do cac tieu quan mat b tac.
+ Te bao gan hoai t rai rac trong tieu thuy, di 2 hnh thc:
- Te bao gan v mang te bao, tan mat, e lai mot khuyet trong thu hut cac ai thc
bao en tap trung thanh am.
- Te bao gan hoai t co lai thanh 1 the cau am ac ai toan (the Councilman).
Neu co nhieu te bao gan hoai t, chung co the ket thanh am tao ra hnh anh
hoai t cau noi (bridging necrosis) ca - ca, trung tam - trung tam, ca - trung
tam.
+ Mat hnh anh cac be gan hng tam trong tieu thuy, goi la roi loan cau truc tieu thuy
(lobular disarray), do tnh trang phong to cua te bao gan gay chen ep cac mao mach
dang xoang.
+ Te bao Kupffer ph ai va tang sinh, bao tng cha ay lipofuscine do hoat ong tieu
huy cac manh vun te bao chet.
+ Khoang ca tham nhap cac te bao viem u loai; cac te bao viem co the tran vao nhu
mo gan lan can, gay hoai t cac te bao gan quanh khoang ca.
+ Bieu mo ong mat tang sinh phan ng, tao ra cac ong mat vi cau truc con tho s.
Hnh 8: Viem gan sieu vi cap: roi loan cau truc tieu thuy (A); The Councilman (1) va cac te bao gan thoai
hoa nc phong to (2), bao tng nhat mau (B); tham nhap te bao viem trong khoang ca (C); Hoai
t cau noi ca - ca (D)
Benh ly Gan 195
4. Viem gan sieu vi man tnh
c xem la viem gan sieu vi man tnh khi co bang chng ve lam sang, huyet thanh hoc va
mo benh hoc cua mot viem gan keo dai hn 6 thang. Kha nang chuyen sang viem gan man tnh
khac nhau tuy theo loai virut viem gan:
- oi vi HAV: khong chuyen sang viem gan man.
- HBV: 90% tre s sinh va 5% ngi ln nhiem HBV b viem gan man, 1/4 trong so nay se
tien trien thanh x gan.
- HCV: 50% chuyen sang viem gan man, phan na so nay tien trien thanh x gan.
- HDV: viem gan man nang thng xuat hien ngi a co nhiem HBV ma nay b nhiem
them HDV.
- HEV: khong chuyen sang viem gan man.
Viem gan man tnh do HBV va HCV co kha nang phat trien thanh carcinom te bao gan.
Ve mat lam sang, viem gan sieu vi man tnh thng c phan biet thanh 2 the vi tien
lng khac nhau, viem gan man tan cong va viem gan man ton tai. Tuy nhien, dien tien va tien
lng cua benh thc ra khong phu thuoc vao hnh thai ton thng ma la vao loai virut viem gan
a b nhiem.
Trieu chng lam sang cua viem gan man rat a dang, benh nhan co the khong co trieu
chng g khac ngoai viec th mau co transaminase tang cao; hoac co trieu chng met moi, kho
, an kem ngon. Tham kham co the thay gan lach hi to, o long ban tay, sao mach (spider
angioma).
Hnh thai ton thng:
Trong viem gan man ton tai (chronic persistent hepatitis), hien tng tham nhap te bao
viem ch gii han trong khoang ca, gom cac limpho bao, ai thc bao va tng bao; cau truc
tieu thuy gan con c bao ton. Dang nay khong tien trien thanh x gan tuy benh nhan van con
mang mam benh keo dai (Hnh 9).
Hnh 9: Viem gan man the ton tai, te bao viem gii han trong khoang ca (A); The tan cong, te bao viem
tham nhap vao tieu thuy, gay hoai t moi gam (1), hoai t om (2) (B); Hoa si cau noi (mau xanh)
sau hoai t cau noi (C).
Trong viem gan man tan cong, cac te bao viem tran ra khoi khoang ca, tham nhap vao
tieu thuy gan, gay hoai t lan lt cac te bao gan ngoai ra, khien cho ng bien gia nhu mo
gan va khoang cua tr nen nham nh, khong eu; v vay kieu hoai t nay co ten la hoai t moi
gam (piecemeal necrosis), hay con goi la hoai t bien (interface necrosis), va c xem la dau
ch cho biet tnh trang benh ang tien trien. Ngoai ra, co the thay hoai t cac te bao gan rai rac
trong tieu thuy (hoai t om). Nhieu te bao gan hoai t se hnh thanh cac hoai t cau noi ca -
Benh ly Gan 196
ca, trung tam - trung tam, ca - trung tam; cac vung hoai t nay se hoa si, ket hp vi
hoat ong tai tao cua te bao gan, dan en x gan. (Hnh 9)
Trong viem gan C man, co them hnh anh cac am limpho bao tap trung tai khoang ca,
co the tao thanh nang limpho; ton thng cac ong mat va te bao gan ong m (con goi la te
bao gan thoai hoa m); trong viem gan B man, co the thay cac te bao gan dang knh m.
5. Viem gan sieu vi toi cap (fulminant hepatitis):
Hau het cac trng hp viem gan sieu vi toi cap la do HAV va HBV, t luc khi benh en
suy gan ch trong vong 2-3 tuan le. Benh nhan co cac trieu chng cua suy gan nh vang da,
benh nao gan, hoi chng gan - than, roi loan ong mau, roi loan nc ien giai, roi loan can
bang acid - baz, nhiem oc mau. T le t vong cao, t 25-90%.
Hnh thai ton thng: gan hoai t toan bo, teo nho con 500-700g lam bao gan nhan
nhum, mat cat mau o hoac xanh mau mat , mem b. Tren vi the, toan bo te bao gan trong cac
tieu thuy b hoai t; khoang ca tng oi con nguyen ven, tham nhap mot t limpho bao va ai
thc bao. (Hnh 10)
Hnh 10: Viem gan toi cap, gan teo nho, bao gan nhan (A); te bao gan hoai t nhieu lam
cho khoang ca va tnh mach trung tam co ve xch lai gan nhau (B)
II. TON THNG GAN DO RU (alcoholic liver disease):

Ton thng gan do ru tng oi thng gap, nhat la trong tnh hnh bia ru c tieu
thu tran lan nh hien nay. Co 3 dang ton thng: gan ong m, viem gan ru va x gan. Cac
ton thng nay co the xuat hien oc lap vi nhau, khong nhat thiet phai theo mot trnh t.
1. Gan ong m (hepatic steatosis): ch sau mot lan uong ru kha kha, a co the thay trong
bao tng te bao gan co nhng giot m nho (con goi la tnh trang ong m tui nho:
microvesicular steatosis). nhng ngi nghien ru, cac giot m trong bao tng ln hn, ay
nhan lech ra ngoai vi te bao (con goi la tnh trang ong m tui ln: macrovesicular steatosis).
Cac te bao gan m khi au ch xuat hien vung trung tam tieu thuy, ve sau co the lan ra
toan bo tieu thuy. Hien tng hoa si bat au xuat hien quanh tnh mach trung tam, lan dan ra
cac mao mach dang xoang xung quanh. Tren ai the, gan ln, co the en 6 kg, mat o mem,
mau vang ong. (Hnh 11)
Hnh 11: Gan m vang ong (A); toan bo te bao gan trong tieu thuy b m (B)
Benh ly Gan 197
2. Viem gan ru (alcoholic hepatitis):
Co cac ac iem hnh thai sau (Hnh 12):
- Hoai t te bao gan, thng xuat hien rai rac tai vung trung tam tieu thuy.
- The Mallory: la the vui ai toan trong bao tng, tao bi cac si keratin va protein roi nui
lai vi nhau.
- Tham nhap BCNTT vao trong tieu thuy va tap trung quanh cac te bao gan thoai hoa,
nhat la nhng te bao co cha the Mallory. Limpho bao va ai thc bao cung i vao khoang ca
va tran vao trong nhu mo.
- Hoa si: trong viem gan cap do ru, luon co hien tng hoa si xung quanh cac xoang
mao mach va tieu tnh mach. Do chuyen hoa sat b roi loan ngi nghien ru nen oi khi co
tnh trang ong hemosiderin trong te bao gan va te bao Kupffer.
Hnh 12: Viem gan ru, tieu thuy tham nhap te bao viem, te bao gan ong m (A);
The Mallory (mui ten, B).
3. X gan ru
La ket cuc cua nhng ngi nghien ru. Khi au, gan x co kch thc ln, nang tren 2
kg, mau nau vang; sau o teo dan, nhan nhum va nang khong ti 1 kg. X gan bat au vi s
hnh thanh cac vach si i t tnh mach trung tam en khoang ca, t khoang ca nay en
khoang ca kia. Cac te bao gan nam ket gia cac vach si hoat ong tang sinh tai tao, hnh
thanh nen cac not nho ong eu (giai oan x gan not nho). Cac not phat trien ln dan va co
not at en kch thc tren 2 cm ng knh. Cac vach si cang phat trien th gan cang teo lai.
Vach si phan cat cac not, tao ra tnh trang x gan hon hp not ln va not nho. Tren vi the, cac
vach si tham nhap limpho bao va co cha cac ong mat tang sinh phan ng; co the thay hnh
anh te bao gan mat, nhng hiem khi thay c the Mallory giai oan nay. (Hnh 13)
Hnh 13: X gan ru giai oan not nho (A) Tren vi the, cac dai si (mau xanh) bao quanh cac not
te bao gan tai tao (tieu thuy gia) (B).
III. TON THNG GAN DO DC PHAM VA HOA CHAT

Gan la c quan chnh gi vai tro chuyen hoa va kh oc cho c the, nen co the b ton
thng bi hang loat dc pham va hoa chat khac nhau theo 3 c che:
- Dc pham va hoa chat co oc tnh trc tiep tren te bao gan.
Benh ly Gan 198
- Dc pham va hoa chat khong co oc tnh, nhng khi vao gan se c chuyen hoa
thanh chat gay oc cho te bao gan.
- Dc pham va hoa chat ong vai tro cua mot hapten, bien protein te bao gan thanh
khang nguyen, kch thch phan ng mien dch gay ton thng te bao gan.
Cac dc pham va hoa chat oc
vi gan c phan thanh 2 nhom:
- Nhom co oc tnh d oan c,
th du nh acetaminophen, ru, tetra-
chlorur carbon (CCl4); neu s dung en
1 lieu nao o hoac u lau th chac chan
se lam ton thng te bao gan.
- Nhom co oc tnh khong the d
oan, th du nh sulfonamid, allopurinol,
aspirin, v.v. Cac thuoc nay ch gay oc
cho te bao gan cua nhng ngi co
phan ng ac ng (idiosyncratic
reaction) ma ta khong the oan trc
Hnh 14: Hoai t trung tam tieu thuy gan do qua lieu
c.
thuoc ha sot acetaminophen.
Hnh thai ton thng gan do dc pham va hoa chat rat a dang, gom co gan ong
m, viem gan cap tnh va man tnh, hoai t trung tam tieu thuy te bao gan, hoai t gan toan bo,
x gan, ton thng mach mau gan (tac tnh mach tren gan, xoang mau trong gan). (Hnh 14)
IV. TON THNG GAN DO MAT
Dch mat do gan tiet ra, la mot dung dch co cha bilirubin trc tiep (bilirubin ket hp), acid
mat, phospholipid, cholesterol va cac chat ien giai; rat can thiet cho s hap thu m tai ruot
non. Tnh trang mat co the xay ra do cac benh ly tai gan, goi la mat trong gan; hoac do tac
nghen ong mat (do viem x hoa, soi, u), goi la mat ngoai gan. Hau qua cua tnh trang mat la
te bao gan b ton thng, tien trien dan en x gan.
Hnh thai ton thng:
ac trng cua tnh trang mat la s hien dien cua sac to mat mau nau xanh trong te bao
gan va cac tieu quan mat, khi au tap trung vung trung tam tieu thuy; nhng se lan dan ra
vung ngoai vi neu tnh trang mat tiep dien, khi o co the thay them hnh anh hoai t te bao
gan rai rac va ong mat trong te bao Kupffer thanh mao mach dang xoang. (Hnh 15)
Trong mat ngoai gan, gan sng to, co mau nau xanh cua sac to mat. Tren vi the, trung
tam tieu thuy co hnh anh mat trong te bao gan va tieu quan mat; khoang ca phu ne, tham
nhap te bao viem n nhan, cac ong mat tang sinh, gian rong, chay ngoan ngoeo, long ong
cha mat co ac. Cac ong mat nay co the v tao thanh cac hoc cha mat, bao quanh bi cac te
bao gan thoai hoa. Cac khoang ca dan dan hoa si, tao ra cac vach si noi nhau, dan en x
gan not nho.
Lien he lam sang: bieu hien cua mat tren lam sang la tnh trang vang da, nga, noi cac
u vang tren da (xanthoma) va hoi chng kem hap thu.
Hnh 15: mat trong te bao gan va tieu quan mat (A), Hoc cha mat gia cac te bao gan (B)
Benh ly Gan 199
V. TON THNG GAN DO ROI LOAN HUYET ONG HOC
Thng gap nhat la tnh trang gan sung huyet tnh do suy tim phai. Gan hi sng, mau tm
o, mat cat giong nh hat cau, nen con goi la gan "hat cau". Tren vi the, cac te bao gan trung
tam tieu thuy b hoai t do b thieu oxy nhieu hn trong khi cac te bao gan quanh khoang ca
van con nguyen ven. (Hnh 16)
Hnh 16: Gan "hat cau" (A); Hoai t trung tam tieu thuy (*) do thieu oxy (B)
VI. X GAN (cirrhosis):

X gan la mot van e ln cua y te cong ong nc ta, do co lien quan en van e nghien
ru va viem gan sieu vi.
C che benh sinh:
Bien oi chnh trong c che gay x gan la tnh trang hoa si tien trien lan toa toan bo gan
va s tai to chc he thong vi tuan hoan trong gan (Hnh 17). gan bnh thng, cac si
collagen typ I va III tap trung trong khoang ca va xung quanh tnh mach trung tam tieu thuy;
cac be te bao gan th c nang bi mot khung li si collagen typ IV nam trong khoang
Disse. Trong x gan, co s tang tong hp cac si collagen typ I va III, tao thanh cac vach si.
Cac mach mau tan sinh trong vach si se ket noi vi cac mach mau trong khoang ca va tnh
mach tren gan, hnh thanh mot loi i vong cho mau (bypass) khong qua nhu mo gan. S tang
tong hp cac si collagen trong khoang Disse se lam bt cac "cua so" te bao noi mo cua mao
mach dang xoang, gay can tr cho s trao oi chat gia te bao gan va huyet tng, lam suy yeu
chc nang tong hp cac protein quan trong cua te bao gan (albumin, yeu to ong mau,
lipoprotein, v.v.), va lam tang khang lc mach trong nhu mo gan (dan en tang ap lc tnh mach
ca, co trng, tr, v.v.).
Hnh 17: C che gay x gan
Cac si collagen trong x gan c tao ra chu yeu bi cac te bao hnh sao (te bao Ito)
nam trong khoang Disse. Bnh thng te bao nay co chc nang d tr vitamin A cho c the.
Benh ly Gan 200
Trong qua trnh phat trien x gan, di tac ong cua cac trung gian hoa hoc (PDGF, TNF,
TGF beta, v.v.) tiet ra bi cac te bao viem man tnh va cac te bao cua nhu mo gan b thng ton
(nh te bao gan, te bao Kupffer, te bao noi mo, te bao bieu mo ong mat); cac te bao hnh sao
se c hoat hoa, tang sinh va bien oi thanh cac nguyen bao si c (myofibroblast), co kha
nang san xuat ra cac si collagen.
Ben canh hoat ong tao si, cac te bao gan con song sot se tang cng hoat ong tang
sinh, tao ra cac not tai tao, bao quanh bi mo si. Ket cuoc gan tr thanh mot mo si cha cac
not te bao gan, he thong vi tuan hoan cung cap mau cho te bao gan cung nh kha nang san
xuat cac protein cua te bao gan b ton hai tram trong. Mat khac, mo si cung pha huy cac ong
mat trong khoang ca, dan en tnh trang mat; cac te bao bieu mo ong mat con song sot se
tang sinh phan ng, tao ra cac ong mat mi vi cau truc kha tho s (con goi la ong mat gia).
Nguyen nhan:
X gan co the do rat nhieu nguyen nhan khac nhau, tai gan hoac ngoai gan, nh: viem
gan sieu vi, ngo oc, nghien ru, mat, cac benh chuyen hoa, suy tim; mot so trng hp x
gan khong co nguyen nhan ro ret (cryptogenic cirrhosis). Trong cac nguyen nhan noi tren;
nghien ru, viem gan sieu vi va mat gi v tr hang au gay x gan vi t le lan lt la 60%,
10% va 5% .
Hnh thai ton thng:
Theo truyen thong, x gan c phan biet thanh 2 dang ai the, x gan not nho (not <
3mm) va x gan not ln (t 3mm tr len), nhng cach phan loai nay khong co y ngha nhieu ve
mat ieu tr cho bang phan loai theo nguyen nhan gay benh; va lai, hnh anh not khong luon co
nh, chang han trong x gan ru, khi au la x gan not nho, nhng ve sau se tr thanh x
gan hon hp not nho not ln. Tren vi the, mo gan x gom cac dai si bao quanh cac not te bao
gan tai tao (tieu thuy gia). Trong not tai tao, co the thay cac te bao gan tang sinh (te bao gan 2
nhan), cac te bao gan thoai hoa nc, te bao gan ong m. Trong mo si, co tham nhap cac
te bao viem man tnh, cac ong mat tang sinh (Hnh 18). Ngoai ra con co the thay them cac hnh
anh ton thng khac, tuy theo nguyen nhan gay x gan.
Hnh 18: X gan not nho (A); X gan not ln (B); Nhuom Trichrome cho thay ro cac not tai tao trong o co
nhieu te bao gan ong m, c bao quanh bi mo si (C); Trong vach si, co tham nhap te
bao viem va tang sinh phan ng cac ong mat (D).
Benh ly Gan 201
Lien he lam sang:

T c che benh sinh a trnh bay tren,
co the hieu c cac trieu chng lam sang
cua x gan nh tang ap lc tnh mach cua,
trng n tnh mach thc quan, co trng, suy
chc nang gan, roi loan ong mau, v.v. (Hnh
19)
Hnh 19: Tran dch mang bung (co trng) do x gan
VII. U GAN
U gan co the lanh tnh hoac ac tnh. oi vi u ac tnh, u th phat do di can en gan thng
gap hn u nguyen phat, va trong cac ung th gan nguyen phat th carcinom te bao gan la loai
thng gap nhat.
1. U lanh mach mau dang hang
La loai u gan lanh tnh thng gap nhat, co cau tao vi the giong u lanh mach mau ni
khac (xem chng benh ly tim mach). U thng nho hn 2cm, mau o tm, mem, nam trong
vung nhu mo di bao gan (Hnh 20). Ch can thiep phau thuat khi u ln, co nguy c v qua bao
gan.
Hnh 20: U lanh mach mau dang hang, nam di bao gan (A); cau tao vi the la cac xoang mach gian rong,
cha ay hong cau (B)
2. U tuyen te bao gan (liver cells adenoma):

La mot loai u lanh tnh hay gap phu n tre co dung thuoc nga thai uong; u se thoai
trien khi ngng thuoc.
U mau vang nau, gii han ro, thng nam trong vung nhu mo di bao gan, kch thc t
vai cm en hang chuc cm. Tren vi the, u cau tao bi cac dai te bao giong te bao gan bnh
thng, phan bo mach mau phong phu nhng khong sap xep c thanh cau truc tieu thuy
gan, khong co tnh mach trung tam va khoang ca. (Hnh 21)
U tuyen te bao gan can c lu y cho no co the gay nham lan vi ung th gan, va do
co v tr di bao gan nen co the v (nhat la khi co thai) gay xuat huyet trong o bung tram trong.
Benh ly Gan 202
Hnh 21: U tuyen nam ngay di bao gan, te bao u giong te bao gan bnh thng, nhieu mach mau.
3. Carcinom te bao gan (hepatocellular carcinoma):

Dch te hoc:
Xuat o carcinom te bao gan (CTBG) cac nc ong nam A cao hn han cac nc Au
My (th du xuat o CTBG Trung quoc la 36/100.000 dan, so vi My la 5/100.000 dan), co le do
lien quan vi tnh trang nhiem HBV kha cao tai ay. Mot a tre nhiem HBV t me luc chao i,
en tuoi trng thanh se co nguy c b CTBG tang gap 200 lan so vi ngi bnh thng. My,
xuat o CTBG trong 20 nam va qua a tang len gap 3 lan, mac du tai ay khong co o lu
hanh cao cua HBV, co the do vai tro cua x gan (chiem 90% benh nhan CTBG) va tnh trang
nhiem HCV.
CTBG xay ra gii nam nhieu hn gii n, vi t le thay oi t 2/1 en 8/1. Ghi nhan ung
th tai Benh vien Ung bu TP.HCM va Benh vien K Ha noi (2004-08) cho thay CTBG ng
hang th 2 va 3 gii nam, th 7 gii n.
Hnh thai ton thng:
- ai the: co 3 dang, mot o, a o hoac tham nhiem lan toa, co khi toan bo gan. Ca 3 dang
eu lam gan ln; u co mau lat hn nhu mo gan xung quanh, mat o mem b, thng co kem
xuat huyet va hoai t. CTBG co khuynh hng xam nhap manh vao cac mach mau, u co the
phat trien vao trong long tnh mach ca va tnh mach chu di. (Hnh 22)
- Vi the: CTBG co the biet hoa tot, va hoac kem. oi vi loai biet hoa tot va va, cac te
bao u con gi c t nhieu ac iem cua te bao gan, hp thanh cau truc dang be (bat chc
be gan Remak) hoac cau truc dang tui tuyen, long tui tuyen co the cha mat do te bao u san
xuat. CTBG phat trien lan rong dan trong mo gan hoac co the tao ra nhng not ve tinh. giai
oan muon, CTBG cho di can theo ng mau len phoi, theo ng bach huyet en cac hach
ron gan, quanh tuyen tu va ong mach chu. (Hnh 23)
Hnh 22: CTBG thuy phai gan, vi 1 not ve tinh (mui ten)
Benh ly Gan 203
Hnh 23: Vi the CTBG, cac te bao u tao thanh tui tuyen trong long cha mat (1), te bao u d dang, co phan
bao (2) so vi te bao gan bnh thng (3) (A); te bao u tao thanh be (4) (B).
Lien he lam sang: trong giai oan au cua CTBG, benh nhan co the co mot so trieu
chng khong ac hieu nh au lam ram vung ha sn phai, cam giac kho , met moi, sut can,
Khi u a ln, co the s thay gan to, chac.
Do hien tng giai c che gen, te bao u co the tai san xuat alpha fetoprotein (AFP); mot
benh nhan ma ket qua sieu am cho thay co 1 khoi choan cho trong gan, ket hp vi ham lng
AFP/mau > 500ng/ml th hau nh chac chan o la CTBG; tuy nhien khoang 20% benh nhan
CTBG khong co AFP tang, do o mot ket qua AFP am tnh th cha u e loai tr CTBG. Ket
qua ieu tr CTBG rat khiem ton, v a so khi phat hien th u a ln hoac do u xuat hien tren nen
x gan, khong the ch nh phau thuat; hoa tr va xa tr khong co vai tro trong ieu tr CTBG.
Tien lng song them 5 nam oi vi u co kch thc 2 - 5cm la 40%, giam xuong con 10% oi u
ln hn 5 cm.
4. Ung th di can gan

Ung th di can gan gap nhieu hn ung th gan nguyen phat. Ung th cua bat ky ni nao
trong c the cung co the di can en gan, nhng thng gap nhat la cac di can t ung th ng
tieu hoa. Dang ai the cua ung th di can thng la ton thng a o, ca 2 thuy gan, co cau
tao vi the giong nh u nguyen phat. (Hnh 24)
Hnh 24: Ton thng a o, ca 2 thuy trong ung th di can gan

Benh ly Gan 204
1.The Councilman:
A/ La te bao gan b hoai t co lai thanh 1 the cau am ac ai toan
B/ Phan bo rai rac trong tieu thuy
C/ c tm thay trong viem gan sieu vi man tnh
2. Gan trong viem gan the toi cap co hnh anh:

A/ Ph ai B/ Teo nho C/ Khong thay oi kch thc
D/ Co cho ph ai, co cho teo nho E/ Co khi ph ai, co khi teo nho
3. The Mallory c tm thay trong:

A/ Viem gan sieu vi B/ Viem gan ru C/ gan mat
D/ X gan tim E/ Viem gan nhiem khuan
4 Te bao gan dang "knh m" la ton thng gay ra bi:

A/ HAV B/ HBV C/HCV D/ HDV E/ HEV
5. KHONG PHAI ac iem vi the cua viem gan ru:

A/ Te bao gan m B/ Te bao gan ong hemosiderin C/ Hoa si
D/ Tham nhap te bao viem trong tieu thuy gia
E/ The Mallory trong bao tng te bao gan
6. Tnh trang hoa si tien trien lan toa trong x gan la do:
A/ Nguyen bao si trong gan tong hp qua mc cac si collagen
B/ Te bao hnh sao (te bao Ito) tong hp vitamin A
C/ Te bao hnh sao chuyen dang thanh nguyen bao si san xuat si collagen
D/ Te bao hnh sao chuyen dang thanh nguyen bao si c san xuat si collagen typ IV
E/ Te bao hnh sao chuyen dang thanh nguyen bao si c san xuat si collagen typ I
7. X gan not nho:

A/ Tren ai the not co kch thc > 3 mm
B/ Gap trong giai oan khi au cua x gan ru
C/ Do te bao hnh sao trong khoang Disse tang tong hp si collagen type IV
D/ Suy tim la nguyen nhan chnh gay loai x gan nay nc ta
8. Carcinom te bao gan:

A/ Xay ra gii nam nhieu hn gii n
B/ Gap nhieu hn ung th di can gan
C/ Tren ai the, co 3 dang: n o, a o va tham nhiem lan toa
D/ Loai biet hoa kem, te bao u hp thanh cau truc dang be(giong be Remak)
E/ Ch co A va C ung
9. Bien phap hu hieu nhat hien nay e lam giam xuat o ung th gan tai Viet nam la :
A/ Khong an thc an moc, oi thiu
B/ Tiem nga vacxin phong nga HBV
C/ Theo doi ham lng AFP trong mau
D/ Theo doi sat benh nhan x gan
E/ ieu tr noi khoa tieu diet virus viem gan
Benh ly he Sinh duc n 205
BENH LY HE SINH DUC N
Muc tieu:
1. Ke c nhng benh ly thng gap am ho, am ao, co than t cung va buong trng.
2. Hieu c moi quan he gia chuyen san gai, nghch san va carcinom co t cung.
Vai tro cua phet mong co t cung trong tam soat ung th co t cung.
3. Mo ta benh hoc nhng u thng gap co t cung, than t cung va buong trng.
4. Mo ta benh hoc cac benh ly nguyen bao nuoi.
BENH LY AM HO
I. BENH VIEM NHIEM:

Viem nhiem am ho thng ket hp vi viem am ao, goi chung la nhiem khuan ng
sinh duc n di (infections of the lower female genital tract). Tnh trang nhiem khuan nay co the
do nhieu loai vi sinh vat khac nhau gay ra, trong o co nhom benh lay truyen qua ng tnh duc
nh benh lau, giang mai, herpes sinh duc, ha cam mem (chancroid), u hat ben (granuloma
inguinale), u hat limpho hoa lieu (lymphogranuloma venereum)... se c trnh bay chi tiet trong
Hoc phan Da lieu. Phan ln cac viem nhiem am ho khong gay nguy hiem cho benh nhan, co the
chan oan chnh xac tren lam sang bi cac thay thuoc phu khoa ma khong can en vai tro cua
nha giai phau benh.
II. TON THNG BIEU MO KHONG TAN SINH (non - neoplastic epithelial disorders)
Bieu mo lat tang cua niem mac am ho co the b teo mong hoac tang san day len; cac ton
thng nay trc ay co ten la nghch dng am ho (dystrophies), nay c goi n gian la ton
thng bieu mo khong tan sinh; e phan biet cac ton thng tan sinh trong bieu mo, la nhng
ton thng tien ung. Phan biet 2 loai ton thng bieu mo khong tan sinh am ho: Liken x hoa
(Lichen sclerosus) va Liken simplex man tnh (Lichen simplex chronicus).
Ca 2 loai ton thng tren eu bieu hien tren lam sang di dang nhng mang trang, c
cac thay thuoc phu khoa goi la bach san (leukoplakia); tuy nhien bach san cung la bieu hien cua
nhieu loai ton thng khac t lanh ti ac nh mat sac to da (vitiligo), benh vay nen, lichen
phang, carcinom tai cho, benh Paget, carcinom te bao gai xam nhap. V vay, bach san am ho
can c theo doi can than va sinh thiet khi can thiet e tranh sot cac ton thng ac tnh.
A. Liken x hoa
La benh da am ho man tnh, xay ra moi la tuoi nhng thng gap nhat tuoi sau man
kinh. Nguyen nhan gay benh cha ro nhng co the co moi lien quan vi cac benh t mien (benh
thieu mau ac tnh, cac benh t mien tuyen giap). Liken x hoa khong phai la ton thng tien
ung, nhng co the lam tang nguy c b ung th am ho ve sau (1-4 % cac trng hp). Benh gay
trieu chng nga, dien tien lau ngay dan en teo hoan toan moi ln va moi nho am ho, hep lo
nieu ao.
Hnh thai ton thng:
- ai the: mang trang, phang nh giay da, b khong eu, co the loet nong.
- Vi the: bieu b teo et va mat nhu bieu b (rete ridges), co the co hien tng tang sng
va tang gai do benh nhan gai nhieu. Lp b nong ngay di mang ay khi au phu ne nhng
cang ve sau cang b x hoa va hyaline hoa; lp b sau ben di thng co hien tng tham nhap
limpho bao (Hnh 1A).
B. Liken simplex man tnh
Liken simplex man tnh thc ra khong phai la mot benh ly rieng biet ma ch la mot phan
ng cua da gay ra bi tnh trang gai hoac cha xat qua mc vung da am ho do nga (thng thay
trong cac viem da do benh cham hoac cac benh da khac).
Hnh thai ton thng:

- ai the: mang trang, day, thng thay vung moi ln; co the thay cac vet tray xc do
gai.
- Vi the: bieu b tang san day len vi hien tng tang sng, tang gai va tang san lp hat;
cac nhu bieu b keo dai. Lp b tham nhap rai rac cac te bao viem man tnh. (Hnh 1B)
Hnh 1: Liken x hoa, moi ln teo, co nhng mang trang phang (A1); tren vi the,
bieu b teo et, lp b nong x hoa va hyalin hoa (A2).
Liken simplex man tnh, moi ln mau trang nhat, day len (B1); tren vi the,
bieu b tang san vi hien tng tang sng, tang gai va tang hat (B2)
III. TAN SINH TRONG BIEU MO AM HO (Vulvar Intraepithelial Neoplasia - VIN):

VIN bao gom cac ton thng nghch san va carcinom tai cho am ho, la ton thng tien
ung cua carcinom te bao gai am ho. VIN co lien quan vi nhiem Human Papilloma Virus typ 16
(70% trng hp) nhng hiem gap typ 18; VIN co the hien dien cung luc vi condylom sui. VIN
thng gap phu n trong o tuoi 35-40; gay ra nhng trieu chng lam sang khong ac hieu
nh nga ngay kho chu, r dch chut t do gai nhieu gay tray xc.
Hnh thai ton thng:
- ai the: ton thng co the n oc hoac nhieu o, co dang cac dat san mau trang, mau
nau do tang sac to hoac mau o hong (con goi la hong san Queyrat).
- Vi the: co hien tng nghch san bieu mo lat tang vi tnh trang roi loan nh hng sap
xep cac lp te bao, mat o te bao tang, te bao to nho khong eu, nhan tang sac d dang, t le
nhan /bao tng, tang t le phan bao tang, v tr phan bao khong con gii han lp ay. Tuy
mc o nghch san, phan biet 3 mc o VIN am ho (Hnh 2):
* VIN1: tng ng vi nghch san nhe, te bao bat thng khu tru 1/3 di cua bieu mo.
* VIN2: tng ng nghch san va, te bao bat thng len en 1/3 gia cua bieu mo.
* VIN3: tng ng nghch san nang (cac te bao bat thng len 1/3 tren be day bieu mo)
va carcinom tai cho (te bao bat thng len en be mat).
Tuy VIN 1 co the thoai trien va t khoi, nhng benh nhan cang ln tuoi ( > 45 tuoi) th kha
nang VIN chuyen thanh carcinom te bao gai xam nhap cang tang; v vay ieu tr tieu chuan oi
vi VIN van la phau thuat cat bo vung ton thng. Khoang 25% trng hp VIN tai phat sau
phau thuat, thng la cac benh nhan VIN co HPV (+).
Hnh 2: Tren cung 1 benh nhan: VIN 1 (A), 1 nam sau thanh VIN 2 (B), 3 nam sau
thanh VIN 3. Vi the cua VIN 1 (D), VIN 2 (E), VIN 3 (F).
IV. U LANH TNH VA TON THNG GIA U:

A. Boc tuyen Bartholin (Bartholins cyst):
La ton thng gia u. Tuyen Bartholin la mot tuyen ong dang
nang, che tiet chat nhay trong. Tnh trang viem nhiem am ho co
the lam tac nghen ong tuyen, chat che tiet tch tu lai tao thanh
boc. ieu tr bang cach m boc tuyen ra da. (Hnh 3)
B. Condylom sui (condyloma acuminatum):
La u lanh tnh, xay ra nhieu nhat nhom phu n tre trong
nhng nam au mi hoat ong tnh duc, do nhiem HPV qua
ng sinh duc, chu yeu la HPV typ 6 hoac typ 11.
Benh thng xuat hien tren c a viem am ao, tieu ng,
uong thuoc nga thai, ve sinh kem, suy giam mien dch, hoat
Hnh 3: Boc tuyen Bartholin
ong tnh duc vi nhieu ngi.
Hnh thai ton thng:
ai the: Condylom co dang nh mun coc, n oc hoac nhieu o, nam rai rac tren da am
ho, cac ton thng co the hoa nhap vi nhau va lan rong en vung da tang sinh mon.
Vi the: Bieu mo tang san tao nhu, co hien tng tang sng, tang gai, can sng (lp sng
van con nhan te bao), nghch sng (te bao gai sng hoa bat thng va tang san lp ay). ac
biet co s hien dien cua te bao rong (Koilocyte), ton thng ac hieu cua tnh trang nhiem HPV,
nam trong cac lp nong va lp trung gian cua bieu mo. Te bao rong co kch thc ln; nhan to,
tang sac, co the co 2 nhan; quanh nhan co mot khoang sang, gii han ro, phan cach vi bao
tng pha ngoai. Mo em ngam te bao viem man tnh. (Hnh 4)
Hnh 4: Condylom am ho co dang mun coc (mui ten, A); Bieu mo lat tang tang san tao nhu (B); Cac te
bao rong (mui ten, C)
Condylom am ho phat trien manh trong vong 6 tuan le, sau o thoai trien t t; mot so
trng hp co the ton tai keo dai. Me mac benh co the lay nhiem virus cho con khi sanh; lam tre
ve sau co the b u nhu thanh quan.
ieu tr bang hoa chat, ot lanh hay ot laser.
V. U AC TNH:
ai a so u ac am ho la u nguyen phat, trong o carcinom te bao gai chiem 85%; so con
lai la carcinom te bao ay, carcinom tuyen va melanom. Mot t trng hp la u di can.
A. Carcinom te bao gai (squamous cell carcinoma):
La loai u ac thng gap nhat am ho. Trc ay, carcinom te bao gai thng xay ra
phu n ln tuoi (> 55 tuoi), hien nay cung vi VIN, tan suat mac benh co xu hng tang cao
nhom phu n tre tuoi hn. Phan biet 2 nhom:
- Nhom co lien quan vi nhiem HPV, typ 16 va 18; thng tien trien trc tiep t cac ton
thng VIN sau khoang 5-7 nam. Trong vung lan can vi carcinom te bao gai, van co the tm
thay cac ton thng VIN khac.
- Nhom lien quan vi liken x hoa va tnh trang tang san bieu mo lat tang do cac benh ly
da khac (nh liken simplex man tnh); ay khong co vai tro cua HPV.
Hnh thai ton thng :
- ai the: Khi au ung th
co the ch la 1 mang trang (bach
san) hoac nau; phat trien ln dan
tao thanh mot khoi choi sui, l loet
hoac tham nhiem cng. U co the
lan rong ra da vung hoi am, xam
nhap vao am ao va trc trang va
cho di can en hach ben va hach
chau; giai oan muon, u di can
theo ng mau en phoi, gan va
cac noi tang khac.
- Vi the: U cau tao bi cac
am te bao gai d dang a pha v Hnh 5: Carcinom te bao gai dang sui tren nen liken x hoa (A);
mang ay va xam nhap vao mo Cac am te bao u xam nhap mo em, biet biet hoa tot,
em; tuy mc o biet hoa tot, va tao c cau sng (B)
hoac kem, co the thay cau sng, cau lien bao hay ch co bao tng bat mau hong do cha
keratin. (Hnh 5)
Lien he lam sang: neu ton thng nho hn 2cm, t le song them 5 nam at 60-80% sau
phau thuat cat bo am ho va nao hach ben; khi ton thng a ln va lan rong, t le nay ch con
10%.
B. Benh Paget am ho
Benh c at ten la benh Paget am ho do co hnh anh vi the giong nh benh Paget
num vu. Khac vi Paget num vu, a so cac trng hp Paget am ho eu khong i kem vi
mot carcinom trong mo em ben di; do vay benh Paget am ho co le xuat phat t cac te bao
non trong bieu b.
Hnh thai ton thng :
- ai the: ton thng co dang mot mang mau o t, b ro, thng thay moi ln.
- Vi the: te bao Paget nam rai rac trong bieu b hoac hp thanh am. Te bao co kch
thc ln hn te bao gai xung quanh; nhan kha d dang, to nho khong eu; phan bao t; bao
tng nhieu va sang. (Hnh 6)
Benh nhan co trieu chng nga hoac nong rat am ho. Benh co the keo dai hang chuc
nam vi te bao Paget lan rong trong bieu b nhng khong xam lan va di can. ieu tr bang phau
thuat cat rong ton thng hoac cat am ho n gian.
Hnh 6: Ton thng benh Paget am ho (A), te bao Paget nam rai rac trong bieu b (mui ten, B)
C. U di can am ho
Chiem 8% cac u am ho, thng gap nhat la u di can t carcinom te bao gai co t cung, ke
o la carcinom noi mac t cung, ung th bang quang va nieu ao.
BENH LY AM AO
I. VIEM AM AO (vaginitis):
Viem am ao rat thng gap, benh thng ngan ngui va khong e lai hau qua nghiem
trong. Am ao co he vi khuan t nhien phong phu, gom ca vi khuan ai kh va k kh, trong o chu
yeu la Lactobacillus. Lactobacillus la vi khuan gram dng, ai kh, co kha nang chuyen hoa
glycogen trong bao tng cac te bao gai thanh axit lactic, tao ra moi trng pH axit trong am
ao, ngan can s sinh soi cua cac vi sinh vat khac.
Viem am ao co the do nhieu loai vi sinh vat khac nhau gay ra nh vi khuan, ky sinh
trung, nam moc. ang chu y la nhieu vi sinh vat trong so nay van song thng tru trong am ao
ma khong gay trieu chng, chang han nh nam candida albicans (c tm thay 5% phu n
bnh thng) hoac ky sinh trung Trichomonas vaginalis (c thay 10% phu n), th nay lai tr
thanh tac nhan gay benh do benh nhan a b nhiem mot chung mi cung loai (thng qua
ng tnh duc) nhng co oc lc cao hn nhieu; hoac khi benh nhan co c a thuan li cho
tnh trang nhiem khuan nh benh tieu ng, s dung khang sinh dai ngay, teo mong niem mac
do man kinh, chan thng, v.v.
Lien he lam sang: viem am ao gay ra huyet trang vi so lng, mau sac, mui, o am
ac thay oi tuy tac nhan gay viem; benh nhan co trieu chng au rat, au khi giao hp, niem
mac am ao sung huyet, o. Xac nh tac nhan gay viem bang cach soi ti huyet trang va s
dung khang sinh thch hp e ieu tr.
II. U
U am ao noi chung t gap, gom co ton thng dang u nh tang sinh mo si dang polyp
(fibroepithelial polyp); vai loai u lanh tnh nh u c trn, u si than kinh; va u ac tnh.
U am ao ac tnh ch chiem 2% cac u ng sinh duc n, trong o 80% la do di can t
mot ung th ni khac, thng gap nhat la t ung th co t cung, than t cung, buong trng,
trc trang va than.
U am ao ac tnh nguyen phat chu yeu la carcinom te bao gai, chiem hn 90% cac trng
hp. Cac loai u ac tnh khac rat hiem gap, bao gom carcinom tuyen, sarcom c van dang chum
nho, v.v.
A. Carcinom te bao gai am ao: benh nhan thng ln tuoi, t 60 - 70 tuoi; u tien trien t mot
ton thng tien ung goi la tan sinh trong bieu mo am ao (vaginal intraepithelial neoplasm -
VAIN) va co lien quan vi tnh trang nhiem HPV nh VIN. VAIN cung c phan thanh 3 mc
o:
* VAIN1: tng ng vi nghch san nhe bieu mo am ao.
* VAIN2: tng ng nghch san va.
* VAIN3: tng ng nghch san nang va carcinom tai cho.
Hnh thai ton thng:
- ai the: ton thng giai oan VAIN thng ch la mot mang niem mac hi day, khong
bat mau lugol, 1/3 tren am ao, thanh trc nhieu hn thanh sau va thanh ben. Khi a tien
trien thanh carcinom te bao gai xam nhap, ton thng co dang choi sui, l loet hoac tham nhiem
cng thanh am ao. Ung th lan rong ra thanh chau, xam nhap vao bang quang va trc trang va
cho di can en hach ben va hach chau. (Hnh 7)
- Vi the: tng t carcinom te bao gai am ho.
ieu tr phau thuat cat bo am ao va t cung khi carcinom te bao gai con khu tru am
ao, t le song them 5 nam at khoang 80 % ; nhng khi ung th a lan rong, t le nay giam con
20%.
Hnh 7 : VAIN 3 khong bat mau Lugol (A) ; Vi the VAIN 3 (B) ; Carcinom te bao gai am ao xam lan
B. Carcinom tuyen nguyen phat am ao: rat hiem gap, thng xay ra phu n tre co me s
dung thuoc diethylstilbestrol (DES) trong thi gian mang thai.
C. Sarcom c van dang chum nho (Botryoid sarcoma): cac be gai, sarcom c van dang
chum nho la u ung sinh duc thng gap nhat. Hau het cac trng hp eu nho hn 5 tuoi,
trong o 2/3 benh xay ra trong 2 nam au i. U xuat phat t lp mo em sat bieu mo, co nguon
goc t trung mo khong biet hoa. U xam nhap vao thanh am ao va vao cac cau truc vung chau.
ai the u co dang nhieu polyp hp lai giong chum nho, nhay nh thach, sa khoi am ao. Tren vi
the, u gom cac nguyen bao c van (rhabdomyoblast) hnh tron hay hnh thoi, bao tng a eosin,
nam trong mo em dang niem va thng tap trung thanh 1 lp day ac ngay sat di bieu mo.
Trong bao tng cua te bao u co the thay van c. U lan rong nhanh, cho di can hach va di can
xa. Benh co tien lng xau, t le song 5 nam la 10-35%. (hnh 8)
Hnh 8: Sarcom dang chum nho, sa khoi am ao (A) Te bao hnh tron hoac hnh thoi,
bao tng ai toan (B), co the thay van ngang trong bao tng (hnh nho)
BENH LY CO T CUNG
Co t cung (CTC) gom co ngoai la phan nho vao trong am ao, c bao phu bi bieu
mo lat tang khong sng hoa va co trong la mot ong hnh tru noi co ngoai vi buong t cung,
c phu bi bieu mo tru n tiet nhay, bieu mo nay gap nep sau vao trong mo em ben di
tao thanh cac khe tuyen. Lo ngoai CTC la ranh gii gia co ngoai va co trong CTC. ng tiep
hp gai - tru la ni noi tiep gia bieu mo tru n cua co trong vi bieu mo lat tang khong sng
hoa cua co ngoai. Khi cha day th, ng tiep hp gai - tru nam ung ngay lo ngoai CTC.
phu n trong tuoi hoat ong sinh duc, tuyen co trong lan dan xuong co ngoai, tao ra vung lo
tuyen CTC, ay ng tiep hp gai - tru ra xa khoi lo ngoai CTC. Trong vung lo tuyen, bieu mo
tru n se chuyen san gai thanh bieu mo lat tang; vung lo tuyen c goi la vung chuyen dang,
vi s hnh thanh mot ng tiep hp gai - tru mi v tr ban au (Hnh 9). en tuoi man kinh,
do tnh trang teo niem mac, ng tiep hp gai - tru cung vi vung chuyen tiep tut sau tr lai
vao trong kenh CTC.
* Hien tng chuyen san gai
e hieu v sao cac benh ly CTC hay xay ra tai vung chuyen dang, can phai hieu ro hn
ve hien tng chuyen san gai. Bieu mo co trong gom 1 lp te bao tru n tiet nhay; gia mat
ay cua te bao nay va mang ay ben di con co mot lp khong lien tuc cac te bao nho nhan
tron tng oi kho tm thay, goi la cac te bao d tr (reserve cells). Cac te bao d tr co chc
nang tng t te bao lp ay cua bieu mo co ngoai, gi nhiem vu sinh san tao ra cac te bao tru
tiet nhay mi thay the cho cac te bao a b h hong bong troc. Khi co lo tuyen CTC, bieu mo co
trong phai thch nghi vi moi trng mi co tnh axt cua am ao bang cach tang san cac te bao
d tr, tao nen cac lp te bao biet hoa theo hng gai, ay dan lp te bao tru n len tren va
cuoi cung hnh thanh nen mot bieu mo lat tang tng t co ngoai (Hnh 10). Chnh do hoat ong
tang san va chuyen san nay ma vung chuyen dang de b tac ong bi cac tac nhan gay viem va
tac nhan sinh u, dan en cac benh ly viem va u cua CTC.
Hnh 9: A- CTC tre gai cha co vung lo tuyen; B- S hnh thanh vung lo tuyen lam ng tiep hp gai-tru
b ay xa khoi lo ngoai CTC; C- Hoat ong chuyen san gai ket cuc a tai tao ra 1 ng tiep hp
gai-tru mi (ng cham cham mau xanh la cay) tien gan en lo ngoai CTC.
Hnh 10: CTC bnh thng, ng tiep hp gai - tru (mui ten, A); Tiep hp gai - tru di knh hien vi (B); Cac
te bao d tr bat mau nau (hoa mo mien dch vi khang the chong KA) nam di lp te bao tru (C); Vung lo
tuyen CTC mau o hn, co cha cac am chuyen san gai (mui ten, D); Vung chuyen dang (E); Te bao d
tr bat au tang san (F); Cac lp chuyen san gai, ay te bao tru len tren (G, H); Vung chuyen dang a
chuyen san gai hoan toan, tr thanh bieu mo lat tang giong co ngoai CTC (I).
I. VIEM CO T CUNG (cervicitis):
Hnh 11: CTC b viem man tnh, sung huyet o (A), Tren vi the, mo em tham
nhap cac te bao viem man tnh va co s hnh thanh nang limpho (B).
La benh ly rat thng gap, gay ra huyet trang am ao. CTC co the b viem cap tnh hoac
man tnh, do nhieu loai vi sinh vat khac nhau nh Streptococcus, Staphylococcus, Enterococcus,
E. coli, Chlamydia trachomatis, virut Herpes simplex typ 2, v.v. Benh nhan b lay qua ng tnh
duc, hoac do s dung bang ve sinh hay dung cu tranh thai a nhiem ban.
Hnh thai ton thng:
Trong viem cap tnh, CTC b sng o, co mu chay ra t lo CTC. Tren vi the, co hien tng
tham nhap bach cau a nhan va phu ne mo em.
Trong viem man tnh, CTC sung huyet va co the b loet trt tren be mat. Tren vi the co
hien tng tham nhap cac te bao viem man tnh. (Hnh 11)
II. U CO T CUNG
A. U lanh tnh va ton thng dang U

1. Polyp co trong CTC (endocervical polyp):
La 1 ton thng gia u, c hnh thanh do qua trnh viem nhiem gay kch thch tang san
bieu mo va mo em. Benh c thay 2-5% phu n, co the gay xuat huyet hoac huyet trang.
Hnh thai ton thng: polyp co dang khoi tron tho ra lo ngoai CTC hoac nam trong
kenh CTC, co hoac khong co cuong; kch thc thng < 3 cm; be mat trn lang, mau hong
nhat. Tren vi the, be mat polyp c phu bi bieu mo tru n tiet nhay cua co trong, co cho
chuyen san gai; mo em si phu ne, mach mau sung huyet gian rong do thng co phan ng
viem i kem. (Hnh 12)
ieu tr khoi han bang cach cat bo hoac nao kenh CTC.
Hnh 12: Polyp co trong CTC (mui ten, A); Tren vi the, polyp c phu bi bieu mo tru n tiet nhay (B).
2. Condylom CTC
Hnh 13: Condylom sui co t cung (A); Condylom phang (mui ten, B); Te bao rong (mui ten) trong cac lp
nong cua bieu mo (C).
Do lay truyen qua ng tnh duc cac HPV typ nguy c thap (typ 6, 11, 42, 44, 53, 54, 62,
66). Condylom CTC co the co dang sui giong am ho hoac dang phang, ton thng gii han ro,
hi go cao hn bieu mo xung quanh. Tren vi the co the trong cac lp nong cua bieu mo ton
thng ac trng cua nhiem HPV la cac te bao rong (Hnh 13).
Condylom CTC la u lanh va a so t thoai trien, mot so trng hp ton tai keo dai va
chuyen thanh ung th khi co nhiem them HPV typ nguy c cao.
B. TAN SINH TRONG BIEU MO CTC (Cervical Intraepithelial Neoplasia CIN):

Hau het cac carcinom te bao gai xam nhap CTC (la loai ung th CTC thng gap nhat)
eu xuat phat t cac ton thng tien ung nam trong vung chuyen dang; cac ton thng co the
a hien dien t hang chuc nam nay, cho phep tam soat phat hien bang khao sat te bao hoc vi
phet mong CTC. Co nhieu he thong at ten va phan chia mc o ton thng tien ung khac nhau
(Hnh 14):
- He thong phan o nghch san cua thap nien 60 the ky trc, phan chia ton thng tien
ung thanh 3 mc o: nghch san nhe, nghch san va va nghch san nang.
- He thong tan sinh trong bieu mo CIN cua thap nien 70 va 80, phan chia 3 mc o: CIN
1, CIN 2, CIN 3 (CIN 3 tng ng vi nghch san nang va carcinom tai cho)
- He thong Bethesda 1991 va 2001, goi ton thng tien ung la ton thng te bao gai trong
bieu mo SIL (squamous intraepithelial lesions) gom 2 mc o: grad thap (LSIL - low SIL),
tng ng vi nghch san nhe va condylom co t cung; va grad cao (HSIL - high SIL), tng ng
nghch san va, nghch san nang va carcinom tai cho.
Cac benh vien cua Tp.HCM hien nay ang s dung he thong CIN trong chan oan mo
benh hoc va he thong Bethesda trong chan oan te bao hoc.
Hnh 14: S tng ng giua cac he thong anh gia ton thng tien ung CTC
Tuoi mac benh thng gap cua CIN la 20-35 tuoi. Cac nghien cu dch te hoc lam sang,
benh hoc, sinh hoc phan t eu a xac nh HPV la nhan to chnh trong c che phat sinh cac
ton thng tien ung va ung th CTC (xem phan papillomavirus trong chng benh hoc u). Ngoai
ra con phai ke en cac yeu to nguy c khac co tac ong vao moi tng tac phc tap gia virut
va c the chu nh tnh trang co nhieu ban tnh, tuoi giao hp lan au sm, sanh nhieu con, hut
thuoc la, suy giam mien dch, nhiem trung phu khoa, i song kinh te xa hoi thap, v.v.
ai the: CIN khong co hnh anh ai the ac trng; CTC co ve bnh thng hoac ch viem
o gay lam lan vi cac viem CTC thong thng. ieu nay cho thay tam quan trong cua cac
khao sat te bao hoc; khi ket qua phet mong CTC bat thng, cho soi CTC co the thay nhng ton
thng gi y nh vet trang, cham ay hoac kham; t o xac nh v tr e sinh thiet va chan
oan mo benh hoc (Hnh 15).
Hnh 15: Hnh anh te bao hoc, soi co t cung va mo benh hoc cua CIN 1 (A1, A2, A3), CIN 2 (B1, B2, B3),
CIN 3 (C1, C2, C3)
Vi the: Trong CIN, qua trnh trng thanh bnh thng cua te bao gai t lp ay len en lp be
mat b roi loan: mat o te bao tang, mat phan cc, te bao co hnh dang va kch thc thay oi,
nhan tang sac meo mo, t le phan bao tang va phan bao khong con gii han lp ay. CIN
c chia thanh 3 mc o:
- CIN1: tng ng vi nghch san nhe, te bao bat thng chiem 1/3 di chieu day bieu
mo.
- CIN2: tng ng vi nghch san va, te bao bat thng chiem 2/3 di chieu day bieu
mo.
- CIN3: tng ng vi nghch san nang (te bao bat thng chiem gan het chieu day bieu
mo, nhng lp te bao be mat van co nhan det giong bieu mo lat tang bnh thng) va carcinom
tai cho (te bao bat thng chiem toan bo chieu day bieu mo).
Ton thng tien ung co the bat au t CIN 1, dien tien t t thanh CIN 2, CIN 3, hoac
ngay t au a la CIN 3. Tuy nhien, co en 50-60% CIN 1 thoai trien, 30% ton tai lau dai khong
tien trien them va ch co 20% tien trien thanh CIN 3, 1-5% dien tien thanh ung th xam lan. CIN
3 co 33% thoai trien, 60-74% tiep tuc tien trien. Qua trnh tien trien cua CIN thanh ung th xam
lan co the dien ra trong nhieu nam, tham ch hang chuc nam.
Lien he lam sang: tam soat CIN da vao te bao hoc, soi t cung va sinh thiet di soi. oi
vi CIN 1, theo doi nh ky bang phet mong Papanicolaou va soi co t cung khi can thiet; oi vi
CIN 2 va CIN 3, ton thng c cat bo bang vong ien (loop electrocautery excision procedure
- LEEP).
Chng trnh tam soat va phong nga ung th co t cung:
Chnh v ton thng tien ung CTC co the keo dai hang chuc nam nen co the tam soat
phat hien sm bang phet mong CTC, trc khi no chuyen sang giai oan ung th xam nhap.
Theo khuyen cao cua Hiep hoi Ung th Hoa ky, oi vi phu n t 18-40 tuoi, can thc hien nh
ky moi 3 nam 1 lan, tren 40 tuoi th moi nam 1 lan. e thc hien phet mong, ngi phu n c
kham phu khoa, dung que go (que Ayre) e cao lay mot t te bao bieu mo t co trong va co
ngoai CTC, trai len tieu ban, nhuom Papanicolaou va quan sat di knh hien vi. Soi co t cung
va sinh thiet e chan oan mo benh hoc neu thay co ton thng nghi ng. (Hnh 16)
V ai a so ung th co t cung co lien he vi HPV, do o co the ngh en viec s dung
vaccin nga HPV e tao ra mien dch chu ong chong nhiem HPV. Hien ang co nhng chien
dch quang cao ram ro va canh tranh rao riet gia 2 che pham vaccin kha at tien, Cervarix
(chong c HPV typ 16, 18, 31, 45) va Gardasil (chong c HPV typ 6, 11, 16, 18); e co hieu
qua th cac vaccin nay phai c dung ngay t khi con tre t 12-17 tuoi (ngha la cha co hoat
ong tnh duc). Thc ra, ca 2 loai vaccin tren ch mi chong c mot so ch khong phai tat ca
cac typ HPV nguy c cao; va phai i 20 nam na mi co the anh gia ay u hieu qua chong
ung th CTC cua cac vaccin nay. V vay theo nhieu tac gia, co mot cach n gian va t ton kem
hn e phong tranh ung th CTC, o la song lanh manh, v chong chung thuy va xet nghiem te
bao hoc eu an.
Hnh 16: Dung cu tam soat ung th CTC, que Ayre (1), km bam sinh thiet (2), mo vt (3) (A); May soi co t
cung (B); kham phu khoa va soi CTC (C).
C. UNG TH CTC:
1. Dch te va yeu to nguy c:
Ung th CTC chiem 10% tong so cac ung th phu n noi chung. Ghi nhan ung th t
2004 en 2008 tai Benh vien Ung bu Tp.HCM va Benh vien K Ha noi cho thay ung th CTC
ng hang th 2 va th 5 trong so 10 ung th thng gap n gii. cac nc phat trien, tan
suat mac benh va t le t vong do ung th CTC giam ang ke nh chng trnh tam soat te bao
hoc, sanh t con va i song xa hoi c cai thien. Tuoi mac benh trung bnh la 40-60 tuoi. Nhan
to chnh trong c che phat sinh ung th CTC la HPV, lay truyen chu yeu qua ng tnh duc.
2. Lam sang
giai oan sm, benh nhan khong co trieu chng hoac ch b xuat huyet am ao sau giao
hp. Khi benh a tien trien, trieu chng lam sang thng gap nhat rong huyet hoac ra huyet
trang keo dai va hoi. Giai oan tre, u an lan ra ngoai t cung chen ep nieu quan gay than
nc, vao bang quang gay tieu mau, do bang quang - am ao, vao trc trang gay do trc trang-
am ao... Ung th di can theo ng bach huyet en cac hach canh CTC, hach chau ngoai,
hach ha v, hach tren on; t khi cho di can theo ng mau.
Giai oan lam sang:
* Giai oan 0: carcinom tai cho (CIN 3).
* Giai oan 1: carcinom con gii han CTC:
1a1: xam nhap vao mo em < 3 mm chieu sau.
1a2: xam nhap mo em > 3 mm nhng < 5 mm chieu sau.
1b : xam nhap mo em nhieu hn giai oan 1a2.
* Giai oan 2: carcinom lan rong ra ngoai CTC nhng cha en thanh chau va 1/3
di am ao.
* Giai oan 3: carcinom lan rong en thanh chau va en 1/3 di am ao.
* Giai oan 4: carcinom lan rong ra ngoai vung chau hoac xam nhap en niem
mac trc trang, bang quang. Giai oan nay a co di can.
3. Hnh thai ton thng:
- ai the: u co the co dang sui (pho bien nhat), loet va tham nhiem.
- Vi the: gom cac loai mo hoc chnh sau:
* Carcinom te bao gai (75-80%)
* Carcinom tuyen (10-15%)
* Cac loai mo hoc khac t gap (<5%): carcinom gai - tuyen, carcinom than kinh
noi tiet, v.v.
a/ Carcinom te bao gai (squamous cell carcinoma): a so carcinom te bao gai CTC xuat
phat t ton thng tien ung nam trong vung chuyen dang; hn 2/3 cac trng hp CIN 3 se phat
trien thanh ung th trong vong 3 - 20 nam neu khong c ieu tr. Tren vi the, phan biet 3 dang
chnh:
Carcinom te bao gai sng hoa: thuoc loai biet hoa tot, grad 1. Te bao u co cac ac iem
ac tnh, co cau lien bao va chat sng trong bao tng, tao c cac cau sng.
Carcinom te bao gai khong sng hoa, loai te bao ln: thuoc loai biet hoa va, grad 2. Te
bao co kch thc ln, d dang, xep thanh tng am, co the thay cau lien bao nhng khong co
cau sng.
Carcinom te bao gai khong sng hoa, loai te bao nho: thuoc loai biet hoa kem, grad 3. Te
bao u kch thc nho, d dang, khong co cau lien bao va cau sng. (Hnh 17)
Hnh 17: Ung th CTC dang sui (A); loet (B); Carcinom te bao gai xam nhap xuat phat t vung chuyen dang
(C); Carcinom te bao gai sng hoa, co cau sng (D); Carcinom te bao gai khong sng hoa, loai te
bao ln (E); Carcinom te bao gai khong sng hoa, loai te bao nho (F).
b/ Carcinom tuyen (adenocarcinoma): gom nhieu loai khac nhau nh carcinom tuyen co
trong CTC (endocervical adenocarcinoma), carcinom tuyen dang noi mac, carcinom tuyen kieu
ruot, carcinom tuyen te bao sang, carcinom gai tuyen trong o, carcinom tuyen co trong la
loai thng gap nhat, chiem 70%. Tuy theo mc o biet hoa, co the thay cac cau truc tuyen ro
ret hoac ch la cac am ac nhieu khi kho phan biet vi carcinom te bao gai biet hoa kem. (Hnh
18)
Hnh 18: Carcinom tuyen co trong (A); Carcinom tuyen dang noi mac (B)
4. ieu tr va tien lng

ieu tr bang phau thuat cat bo t cung va 2 phan phu oi vi ung th giai oan 1, cac
giai oan muon hn oi hoi phoi hp them xa tr va hoa tr. Tien lng benh nhan phu thuoc ro
ret vao giai oan lam sang. T le song them 5 nam cho giai oan 1, 2, 3 va 4 lan lt la 80-95%,
75%, 35% va 15%.
BENH LY THAN T CUNG
T cung ngi trng thanh co hnh

qua le gom phan CTC va than t cung. Buong
t cung co hnh tam giac, lot bi noi mac t
cung, bao xung quanh la thanh c day va ngoai
cung la lp thanh mac (Hnh 19). Noi mac t
cung co cau tao gom cac tuyen noi mac va mo
em noi mac. Trong giai oan hoat ong sinh
duc, noi mac se co nhng bien oi theo chu ky
di anh hng cua noi tiet to estrogen va
progesterone t buong trng. Mot chu ky cua
noi mac t cung (chu ky kinh nguyet) gom co 3
ky: phat trien, che tiet va hanh kinh. Trong ky
hanh kinh, 2/3 tren cua lp noi mac goi la lp
chc nang se bong troc ra, ch con lai lp ay.
Hnh 19: S o cau truc t cung
I. VIEM
Viem noi mac t cung co the gay sot, au bung vung chau va thng co xuat huyet t
cung bat thng.
A. Viem noi mac t cung cap tnh (acute endometritis):
Viem noi mac t cung cap thng xay ra sau say thai, sau sinh va dung dung cu trong t
cung (nao buong t cung - at vong tranh thai - khoet chop). Tac nhan gay viem thng la lien
cau trung, tu cau trung, lau cau trung va Clostridium welchii i t CTC len. Khao sat vi the co
the thay bach cau a nhan tap trung thanh o trong mo em, tao thanh cac o ap xe nho hoac
trong long cac ong tuyen, lam v ong tuyen. (hnh 20B)
Nao sinh thiet buong t cung giup chan oan va gop phan ieu tr nh lay ra c cac mo
hoai t trong long t cung.
Hnh 20: Vong tranh thai trong t cung (A); Viem noi mac t cung cap tnh, mu trong long ong tuyen va mo
em noi mac t cung (B). Viem noi mac t cung man tnh (C)
B. Viem noi mac t cung man tnh (chronic endometritis):

Viem noi mac t cung man tnh thng gap trong trng hp sot nhau sau say thai, sau
sinh, viem vung chau, t cung co vong tranh thai. Tac nhan gay viem man tnh thng la vi
khuan thong thng, nhng cung co the do mot so tac nhan ac biet nh vi khuan lao,
Chlamydia trachomatis, 1 so loai virut nh HPV, virut Herpes Simplex, Cytomegalovirus; trong
nhieu trng hp khong tm thay c cac tac nhan gay benh. Tren vi the, noi mac t cung
tham nhap nhieu te bao viem n nhan nh tng bao, limpho bao. Tnh trang viem lam cac
tuyen trng thanh nhieu mc o khac nhau va cac te bao mo em bien dang thanh hnh thoi
nen kho anh gia giai oan noi tiet cua noi mac (hnh 20C).
II. BENH TUYEN C (Adenomyosis):

Benh tuyen c la tnh trang co cac o tuyen va mo em noi mac bnh thng nam sau
trong lp c t cung. Khoang 1/5 cac trng hp cat t cung phat hien thay co benh tuyen c.
Benh sinh khong ro. Benh nhan khong co trieu chng hoac b au moi khi hanh kinh do mau
kinh nguyet b ket trong lp c.
Hnh thai ton thng:
- ai the: t cung to thng thanh sau, mat cat c t cung co dang be, mem, co the co
nhng vung mau vang nau, tao nang nho.
- Vi the: co s tang sinh cac o tuyen va mo em noi mac nam xen gia lp c, tuyen noi
mac thng ky phat trien (Hnh 21).
Hnh 21: Hnh anh ai the cua benh tuyen trong c (A); Cac o noi mac trong c t cung (mui ten, B)
III. LAC NOI MAC T CUNG (Endometriosis):

La tnh trang co cac o tuyen va mo em noi mac bnh thng nam ngoai t cung. Tnh
trang nay xay ra 5-10% phu n trong tuoi sinh e va se bien mat khi man kinh. V tr lac noi
mac thng gap la mat ngoai buong trng, day chang rong, voi trng, bang quang, trc trang,
tui cung Douglas. C che gay lac noi mac co le do cac manh noi mac bong ra khi hanh kinh a
i ngc voi trng en cay ghep len cac v tr noi tren. Trieu chng lam sang noi bat cua lac noi
mac la tnh trang au bung khi hanh kinh, 1/3 benh nhan b vo sinh.
Hnh thai ton thng:
- ai the: cac o lac noi mac co mau vang nau, xanh nau, hoac o, co the hoa boc, trong
cha dch xuat huyet cu (do xuat huyet khi hanh kinh).
- Vi the: cac am tuyen va mo em noi mac, mo si xung quanh, co nhieu ai thc bao
ong hemosiderin (Hnh 22).
Hnh 22: Cac v tr lac noi mac t cung (cham o, A); Cac not lac noi mac mau nau xanh buong trng (B);
Cac am tuyen va mo em noi mac t cung trong mo em buong trng (C)
iV. TANG SAN NOI MAC T CUNG (endometrial hyperplasia):

Bnh thng, tac ong kch thch gay tang san cua estrogen tren noi mac t cung se b
kiem che bi tac ong bao ve cua progesteron. Khi nong o estrogen tang qua cao va u lau so
vi nong o progesteron, cac tuyen noi mac se b kch thch qua mc, gay ra tang san noi mac
t cung. Cac nguyen nhan gay tang san noi mac t cung gom: cac chu ky khong rung trng, hoi
chng buong trng a nang, cac khoi u buong trng tiet estrogen (u te bao hat), ieu tr bang
estrogen, beo ph. Tang san noi mac t cung thng gap phu n quanh tuoi man kinh.
Hnh thai ton thng:
- ai the: lp noi mac co the day toan bo hoac khu tru di dang giong mot polyp, mat o
mem, mau hong nhat. Khi nao sinh thiet ra c nhieu mo hn bnh thng.
- Vi the: da tren hnh thai te bao va cau truc tuyen, phan biet cac loai tang san noi mac
t cung sau (theo To chc Y te The gii):
- Tang san n gian
- Tang san phc tap
- Tang san n gian khong ien hnh
- Tang san phc tap khong ien hnh
* Tang san n gian (simple hyperplasia without atypia): la loai tang san noi mac t cung
thng gap nhat. Cac tuyen noi mac gia tang so lng so vi mo em, te bao tuyen co nhan
keo dai, eu, lech ve cc ay, gia tang. Cac tuyen dan n tao boc, kch thc to nho khong eu,
thng co goc hoac choi, mo em quanh tuyen con nhieu.
* Tang san phc tap (complex hyperplasia without atypia): hnh thai te bao tuyen cung
giong nh trong tang san n gian ien hnh, nhng cau truc tuyen phc tap hn. Tuyen tang
san phan nhanh phc tap, nam chen chuc nhau, vi t mo em quanh tuyen.
* Tang san khong ien hnh (atypical hyperplasia): te bao tuyen khong ien hnh tang san
chong chat nhieu lp te bao, nhan to tron, nhiem sac chat tho, hach nhan ro, mat phan cc, t le
phan bao tang. Cau truc tuyen co the n gian (goi la tang san n gian khong ien hnh)
hoac phc tap (goi la tang san phc tap khong ien hnh). Tang san phc tap khong ien hnh
thng gap hn so vi tang san n gian khong ien hnh. (Hnh 23)
Ch co 2% tang san noi mac n gian va phc tap tien trien thanh carcinom, trong khi co
en 23% tang san khong ien hnh tien trien thanh carcinom.
Hnh 23: Tang san noi mac t cung n gian (A); Tang san phc tap (B); Tang san phc tap khong ien
hnh, o phong ai nho (C) va o phong ai ln (D).
V. U LANH
A. Polyp noi mac t cung
Polyp noi mac t cung la mot u that, do s tang sinh cua cac te bao mo em noi mac co
tnh chat n dong. Thng gap phu n quanh tuoi man kinh, polyp noi mac co the gay xuat
huyet t cung bat thng.
Hnh thai ton thng:
- ai the: polyp thng ay t cung, kch thc khoang 0,5-3 cm, polyp ln co the tho ra
ngoai am ao qua lo CTC. (Hnh 24)
- Vi the: polyp co mo em x, nhieu mach mau thanh day. Trong mo em co nhieu tuyen
noi mac gian rong. Be mat polyp phu lp bieu mo noi mac thng b loet troc hoac xuat huyet.
Polyp noi mac la 1 u lanh tnh; tuy nhien, khoang 0,5% polyp co kem theo mot carcinom
tuyen.
Hnh 24: ai the va vi the cua mot polyp noi mac ay t cung.
B. U c trn t cung (uterine leiomyoma):

La loai u thng gap nhat t cung. Neu gop luon nhng trng hp u nho vai milimet th
co en 75% phu n tren 30 tuoi co u c trn t cung. Estrogen kch thch u phat trien. U ln
nhanh khi co thai va thoai trien dan sau man kinh. U co the khong co trieu chng hoac gay au
tran bung di, ra huyet am ao bat thng. U di noi mac t cung thng gay xuat huyet do
chen ep noi mac. Cac u ln lam bien dang t cung va phat hien c khi tham kham vung chau.
Nhng u co cuong co the b xoan va hoai t do nhoi mau.
Hnh thai ton thng:
- ai the: thng co nhieu u. U hnh tron, chac, gii han ro vi mo c xung quanh. Mat cat
trang xam, co dang cuon. Kch thc t vai mm en 30 cm. U co the nam trong c, di noi mac
va di thanh mac. U di noi mac co the co dang polyp, tho ra ngoai am ao qua lo CTC, goi
la u c trn xuat ngoai. U co the xuat huyet khu tru, hoai t, thoai hoa boc hay hyalin.
- Vi the: te bao u hnh thoi giong te bao c trn vi nhan hnh bau duc co 2 au tu, bao
tng nhieu, a eosin. T le phan bao thap. Te bao u xep thanh bo. Trong hn 60% u c trn t
cung co hien tng thoai hoa hyalin va x hoa; 10% u c trn co xuat huyet khu tru; 4% co thoai
hoa boc va hoa voi (hnh 25).
ieu tr bang phau thuat boc tach u hoac cat bo toan bo t cung khi u qua ln.
Hnh 25: U lanh c trn than t cung co gii han ro (A); U dang polyp tho ra am ao (B); Te bao u hnh
thoi, nhan hnh bau duc, xep thanh bo (C)
VI. U AC
Ung th cua than t cung a so la carcinom tuyen noi mac; cac loai u ac khac nh
sarcom mo em noi mac, carcinosarcom, v.v. ch chiem khong qua 2 %.
Carcinom tuyen noi mac t cung (endometrial adenocarcinoma):
Carcinom noi mac t cung chiem t le 7% ung th xam nhap phu n. Tan suat mac
benh cao chau Au va Bac My nhng thap chau A, chau Phi va Nam My. Benh thng xay ra
trong o tuoi 55-65, t thay phu n < 40 tuoi. Ghi nhan co s gia tang tan suat ung th nay
nhng ngi mac benh beo ph, tieu ng, cao huyet ap, oc than khong con.
C che benh sinh:
Co nhieu bang chng cho thay moi lien quan gia tang san noi mac t cung va carcinom
tuyen noi mac:
- nhng ngi beo ph hoac b roi loan kinh nguyet do chu ky khong rung trng, co s
gia tang xuat o cua ca 2 benh ly, tang san noi mac va carcinom tuyen noi mac.
- Nguy c carcinom tuyen noi mac gia tang nhng trng hp u buong trng co che tiet
estrogen (u te bao hat) va nhng ngi co dung lieu phap hormon estrogen thay the e ieu
tr mot so benh, th du nh roi loan tien man kinh.
Do vay, phan biet 2 nhom carcinom tuyen noi mac t cung:
- Nhom co lien quan vi tnh trang kch thch estrogen keo dai va tang san noi mac t
cung: u thng co o biet hoa cao, dien tien cham va tien lng tot. Nhom nay chiem 80-85%
cac trng hp carcinom tuyen noi mac, benh nhan thng tre tuoi hn nhom sau.
- Nhom khong co lien quan vi tnh trang kch thch estrogen va khong co tang san noi
mac t cung: u co o biet hoa kem, tien lng xau. Nhom nay chiem 10-15% cac trng hp
carcinom tuyen noi mac, benh nhan thng ln tuoi, a man kinh va co noi mac t cung teo et.
Hnh thai ton thng:

- ai the: u co dang polyp hoac mot am san sui an lan toan bo lp noi mac t cung. U
phat trien xam nhap trc tiep qua thanh c t cung vao cac cau truc xung quanh t cung; u co
the theo ong dan trng lan tran vao trong o bung. giai oan muon, ung th di can en cac
hach vung nh hach chau, hach ben; di can theo ng mau en phoi, gan, xng hoac nao.
- Vi the: hnh anh thay oi tuy theo mc o biet hoa.
* Carcinom biet hoa tot (grad 1): te bao ung th t d dang, a so tao lap c ong tuyen,
co khi xep thanh dang nhu hay dang sang, ch co <5% la cac am ac.
* Carcinom biet hoa va (grad 2): t le am ac te bao trong mo bu t 5-50%, nhan te
bao d dang t hoac trung bnh.
* Carcinom biet hoa kem (grad 3): t le am ac >50% mo bu, te bao rat d dang, nhieu
phan bao. (Hnh 26)
Hnh 26: Carcinom tuyen noi mac t cung co choi sui lap het long t cung (A); Loai biet hoa tot tao c ong
tuyen, o phong ai nho (B1) va ln ( B2); Loai biet hoa kem chu yeu la cac am ac, o phong ai nho
(C1) va ln (C2).
Lien he lam sang: Carcinom tuyen noi mac lam t cung to ra, gay xuat huyet am ao bat
thng kem nhieu huyet trang; e chan oan, can phai nao sinh thiet buong t cung. ieu tr
bang phau thuat cat t cung va 2 phan phu, co hoac khong ket hp vi xa tr va hoa tr, tuy theo
mc o lan rong cua ung th. T le song them 5 nam co the at en 95% neu ung th gii han
trong t cung, nhng ch con 10-30% neu a lan rong ra ben ngoai.
BENH LY NGUYEN BAO NUOI THAI KY
Trong nhau bnh thng co 3 loai nguyen bao nuoi: n bao nuoi (cytotrophoblast),
nguyen bao nuoi trung gian (intermediate trophoblast), hp bao nuoi (syncytiotrophoblast).
Nguyen bao nuoi phat trien phoi hp vi long nhau goi la nguyen bao nuoi long nhau (villous
trophoblast), cac nguyen bao nuoi ni khac goi la nguyen bao nuoi ngoai long nhau (extravillous
trophoblast). Nguyen bao nuoi long nhau gom co a so la n bao nuoi va hp bao nuoi (Hnh
27). Ngc lai, nguyen bao nuoi ngoai long nhau xam nhap vao vach t cung tai ni bam nhau
th gom chu yeu la cac nguyen bao nuoi trung gian va 1 so t n bao nuoi va hp bao nuoi.
n bao nuoi la te bao hnh a giac co
1 nhan tron, bao tng sang hay co hat, gii
han te bao ro, co mot t hoat ong phan bao.
Hp bao nuoi la te bao a biet hoa
cao, tiep xuc vi tuan hoan cua me, san
xuat ra nhieu noi tiet to cua nhau ma quan
trong nhat la HCG (Human chorionic
gonadotropin). ay la nhng te bao ln
nhieu nhan, bao tng bat mau a sac va co
nhieu khong bao, khong co hoat ong phan
bao.
Nguyen bao nuoi trung gian hnh a
giac hoac hnh thoi, ln hn n bao nuoi, co
1 nhan, bao tng ai toan co vai khong bao.
Hnh 27: Long nhau bnh thng vi n bao nuoi (mui
ten) va hp bao nuoi (*)
Benh ly nguyen bao nuoi thai ky (gestational trophoblastic diseases) la mot nhom cac u
va ton thng dang u co tiem nang ac tnh, gay ra bi s tang sinh cac nguyen bao nuoi lien
quan vi thai ky. Sau ay la mot so benh ly nguyen bao nuoi thng gap:
A. NHAU NC TOAN PHAN VA BAN PHAN (complete and partial hydatidiform mole):
Nhau nc co the xay ra bat ky tuoi nao trong giai oan sinh e, nhng nhng phu n
tre hn 20 hoac ln hn 40 tuoi th co nguy c mac benh cao hn. Cac benh nhan co tien can
say thai hay nhau nc de b nhau nc trong cac lan mang thai ke tiep.
Ve di truyen hoc, 90% nhau nc toan phan co bo nhiem sac the la 46XX, nhng 2X eu
la cua cha, do s nhan oi bo nhiem sac the n boi cua tinh trung ben trong 1 noan rong,
khong co ADN cua me. 10% nhau nc toan phan co bo nhiem sac the 46XX hoac 46XY, do
thu tinh cua 2 tinh trung 23X va 23X hoac 23X va 23Y vao trong 1 noan rong. Bo nhiem sac the
cua nhau nc ban phan thng la tam boi vi bo nhiem sac the la 69XXX hoac 69XXY, do thu
tinh cua 2 tinh trung 23X va 23X hoac 23X va 23Y vao trong 1 noan 23X. (Hnh 28)
Cac khao sat bang hoa mo mien dch cho thay cac n bao nuoi khong tiet ra noi tiet to;
cac noi tiet to nh HCG (Human Chorionic Gonadotropin), HPL (Human Placenta Lactogen)
c tiet bi nguyen bao nuoi trung gian va hp bao nuoi.
Noan bnh thng
Hnh 28: Bo nhiem sac the cua nhau nc toan phan va ban phan
1. Nhau nc toan phan (complete hydatidiform mole):
ay la benh nguyen bao nuoi thng gap nhat. Nhau nc thng c phat hien trong
khoang thi gian t tuan le 8 en 12 cua thai ky do trieu chng ra huyet am ao hoac rt cac
manh mo nhau nc ra ngoai. Benh nhan co t cung ln hn tuoi thai va 25% benh nhan co
trieu chng tien san giat hoac nghen nang. HCG trong mau va nc tieu tang cao. Sieu am thay
hnh anh bao tuyet trong t cung, ac thu cua benh nhau nc.
Hnh thai ton thng:
- ai the: cac long nhau ph ai, phu ne, co dang nh chum nho, kch thc thay oi t
vai milimet en 1,5 cm.
- Vi the: cac long nhau khong co mach mau, gia la 1 xoang cha dch. Cac te bao nuoi
tang san manh quanh cac long nhau gom cac n bao nuoi, hp bao nuoi va nguyen bao nuoi
trung gian va co the thay hnh anh d dang te bao. (Hnh 29)
Hnh 29: Long nhau ph ai nh chum nho (A); Long nhau phu thoai hoa nc khong co mach mau, tang
san manh cac n bao nuoi va hp bao nuoi (B,C).
Nhau nc toan phan c ieu tr bang phng phap nao hut va theo doi ham lng
HCG trong mau; neu HCG van khong giam hoac tiep tuc tang len th phai bo sung bang hoa tr.
ang s nhat la bien chng chuyen thanh carcinom em nuoi, xay ra 2,5% so benh nhan du
a c nao hut.
2. Nhau nc ban phan (partial hydatidiform mole):
Nhau nc ban phan chiem 25- 43% nhau nc, thng c phat hien tre hn so vi
nhau nc toan phan, tren cac thai say trong khoang thi gian t tuan le th 12 en 18 cua thai
ky. Trieu chng lam sang giong nh trong nhau nc toan phan nhng t cung thng nho so
vi tuoi thai. HCG tang t hoac khong tang.
Hnh thai ton thng: (Hnh 30)
- ai the: So lng mo nhau t, (khoang 100-200 cm3), co tui thai, banh nhau gom cac
long nhau ph ai ket hp vi cac long nhau bnh thng.
Hnh 30: Nhau nc ban phan, long nhau ph ai (mui ten) canh long nhau bnh thng (A);
Long nhau phu thoai hoa nc (*) ben canh long nhau bnh thng (B).
- Vi the: Ben canh cac thanh phan thai va long nhau bnh thng, co cac long nhau ph
ai thoai hoa nc. Te bao nuoi tang san t hn so vi nhau nc toan phan va khong co d
dang te bao.
Nhau nc ban phan rat hiem khi chuyen sang carcinom em nuoi, do o ch can theo
doi ham lng HCG trong mau e loai tr the benh ang ton tai.
3. Nhau nc xam nhap (invasive hydatidiform mole):

Nhau nc goi la xam nhap khi co long nhau thoai hoa nc xam nhap vao lp c trn t
cung va cac khoang mach mau. Khi a vao long tnh mach, long nhau thoai hoa nc co the gay
huyet tac nhng ni xa nh nao, phoi, mach mau. e chan oan c loai benh ly nay, co khi
phai cat bo t cung e khao sat. Phan ln benh nhan eu ap ng vi hoa tr. (Hnh 31)
Hnh 31 : Nhau nc xam nhap vao lp c trn t cung (A), long nhau thoai hoa nc trong lp c
4. Carcinom em nuoi (choriocarcinoma):

Carcinom em nuoi la u ac tnh xuat phat t nguyen bao nuoi. Nh vay, carcinom em
nuoi co lien quan ti thai ky ch khong n thuan la bien chng cua nhau nc toan phan; vi
xuat o 1/160.000 thai ky bnh thng, 1/15.000 say thai, 1/5.000 thai ngoai t cung, 1/40 nhau
nc toan phan.
Hnh thai ton thng:
- ai the: U co dang 1 khoi xuat huyet hoai t o sam vi be mat lui sui.
- Vi the: U gom 2 loai te bao, cac am n bao nuoi va hp bao nuoi tang sinh d dang,
xam nhap vao lp c t cung, chui vao trong long mach. T le phan bao cao, nhieu am xuat
huyet hoai t nhng khong co cac long nhau. (hnh 32)
U thng sm cho di can theo ng mau en en phoi, am ao, nao, gan, than. Tuy
nhien ay lai la mot loai ung th co ap ng rat tot vi hoa tr, vi t le song con at gan 70%
cho du a co di can.
A
Hnh 32: Carcinom em nuoi co dang mot khoi xuat huyet hoai t xam nhap thanh t cung (A); n bao
nuoi va hp bao nuoi d dang, khong co long nhau (B)
BENH LY BUONG TRNG
Benh ly thng gap nhat buong trng la cac u. Benh ly viem rat hiem gap.
U buong trng co the la nguyen phat hoac th phat (Hnh 33).
- U nguyen phat cua buong trng xuat phat t:
+ Bieu mo be mat buong trng (surface epithelial tumors) (65 - 70%)
+ Mo em day sinh duc (sex cord stromal tumors) (10%)
+ Te bao mam (germ cell tumors) (15 - 20%)
- U th phat cua buong trng: do di can t ung th ni khac (5%)
Hnh 33: Phan loai cac u buong trng theo nguon goc xuat phat
I. U BUONG TRNG NGUYEN PHAT
A. U BIEU MO BUONG TRNG (epithelial tumors):

U xuat phat t lp te bao trung mac phu tren be mat buong trng (con goi la bieu mo be
mat) hoac t nhng nang trong mo em (c hnh thanh do bieu mo be mat b vui vao mo em
sau khi trng rung). Nhng te bao nay co kha nang chuyen san va tang sinh thanh nhieu loai u
bieu mo be mat khac nhau, co the giong bieu mo co trong CTC (u dch nhay), bieu mo noi mac
t cung (u dang noi mac), bieu mo voi trng (u dch trong).
U bieu mo buong trng co the lanh, ac hoac giap bien ac. U giap bien ac la nhng u co
cau truc mo va te bao tang sinh khong ien hnh trong co ve ac tnh, nhng a so lai co dien
tien lanh tnh, khong xam nhap va di can. U ac bieu mo chiem 90% cac u ac cua buong trng.
U bieu mo buong trng xay ra ngi tren 20 tuoi. Phan biet 5 loai:
1. U dch trong buong trng (serous tumors):
La loai u buong trng thng gap nhat, chiem 20-50% tat ca cac loai u buong trng; trong
o 60% la lanh tnh, 15% giap bien ac va 25% ac. U dch trong ac tnh la loai u ac thng gap
nhat cua buong trng.
U lanh thng gap la tuoi 30-40 tuoi, u ac thng gap la tuoi 45-65 tuoi.
Hnh thai ton thng:
- ai the: u co kch thc trung bnh 5-10 cm, co khi rat ln, khoang 30 cm. U lanh thng
co dang boc, vo boc mong, trn lang, cha dch trong. 25% trng hp u lanh co hai buong
trng. oi vi u ac tnh, t le co u hai buong trng cao hn, vo boc u co nhieu nhu va am ac.
-Vi the: Trong u lanh, vach boc c lot bi bieu mo tru n tiet dch trong co long
chuyen. Trng hp ac tnh, lp bieu mo tang san nhieu lp, te bao d dang, tao nhu, xam nhap
vao mo em ben di va ac biet hay thay co cac the cat (psammoma). (Hnh 34)
Hnh 34: U dch trong lanh co vach trn lang (A); U giap bien ac, vach co choi nhu (B); U ac tnh, nhieu nhu
va am ac (C); u lanh, vach boc lot bi bieu mo tru n co long chuyen (D); U giap bien ac,
nhu tang san phc tap nhng khong xam nhap mo em (E); U ac, xam nhap mo em, co the cat (F).
2. U dch nhay buong trng (mucinous tumors):

Chiem 15-25% tat ca u buong trng, 80% lanh tnh, 10% giap bien ac, 10% ac. U dch
nhay ac tnh chiem 10% cac ung th buong trng.
La tuoi mac benh thng gap giong nh u dch trong buong trng.
Hnh thai ton thng:
- ai the: u co kch thc trung bnh ln hn u dch trong va la loai u ln nhat trong cac u
buong trng. U dang boc, mat ngoai lang, mat trong co nhieu vach ngan chia boc thanh nhieu
khoang nho cha dch nhay ac giong keo. U giap bien ac va u ac co nhieu choi nhu va not ac.
5% u lanh co 2 buong trng, t le nay u ac la 20%. (Hnh 35-ABC)
Hnh 35-ABC: U dch nhay lanh co vach trn lang, ngan nhieu boc nho (A); U giap bien ac, vach
co choi nhu (B); U ac tnh, nhieu nhu va am ac (C).
- Vi the: trong u lanh, vach boc lot bieu mo tru n tiet nhay. Trng hp ac tnh, lp bieu
mo tang san nhieu lp, te bao d dang, tao nhu, xam nhap vao mo em ben di. (Hnh 35-
DEF)
Hnh 35-DEF: U dch nhay lanh co vach boc lot bi bieu mo tru n tiet nhay (D); u giap bien ac tang san
tao nhu, nhan tang sac khong ien hnh nhng cha xam nhap mo em (E); U ac xam nhap mo em (F).
3. U dang noi mac t cung (endometrioid tumour):

Chiem 5% u buong trng, khac vi u dch trong va u dch nhay buong trng; hau het u
dang noi mac t cung cua buong trng la u ac tnh, chiem 15-25% ung th buong trng. Trong
30% trng hp, u co ca hai buong trng. U thng gap la tuoi 40-50.
Hnh thai ton thng:
- ai the: u co kch thc 10-20 cm, dang ac, mem; hoac dang boc cha dch nau co
choi nho vao long boc.
-Vi the: u dang noi mac t cung ac (con c goi la carcinom tuyen dang noi mac cua
buong trng) co hnh vi the giong carcinom tuyen noi mac cua t cung (hnh 36).
Hnh 36: U dang noi mac t cung, co vung ac, vung nang (a); Vi the giong carcinom noi mac t cung (B)
4. U te bao sang (clear cell tumor):

Chiem 5-10% cac ung th buong trng.
Hau het u te bao sang la u ac tnh. U lanh va u giap bien ac rat hiem gap. Rat hay i kem
vi lac noi mac t cung vung chau. Tuoi mac benh trung bnh la 57 tuoi, benh nhan thng a
man kinh.
Hnh thai ton thng:
- ai the: u co kch thc trung bnh 15 cm, na ac na nang, thng co xuat huyet hoai
t trong vung ac; trong 40% trng hp, u co hai buong trng.
-Vi the: trong carcinom tuyen loai te bao sang, te bao u hnh a dien, bao tng nhieu va
sang, xep thanh cau truc ong, nhu, hoac am ac nam tren mo em si mach hoac mo em
hyaline hoa. (Hnh 37)
Hnh 37: U te bao sang ac tnh dang choi sui xuat hien trong 1 boc lac noi mac buong trng (A); te bao
u co bao tng sang, xep thanh ong nam tren mo em hyalin hoa (B)
5. U Brenner (Brenner tumors):

Chiem 2% u buong trng. Hau het la u lanh (98%), u giap bien ac va u ac rat hiem gap.
La tuoi thng gap la 30-60 tuoi. Trong 8% trng hp, u co ca hai buong trng
Hnh thai ton thng:
- ai the: u thng co kch thc nho < 2 cm, ch co 10% u ln hn 10 cm. U dang ac,
gii han ro, mat o chac, vang nhat, oi khi co nhng boc nho.
- Vi the: u Brenner cau tao bi cac am te bao bieu mo giong nh bieu mo chuyen tiep
cua ng tiet nieu, nhan co ranh doc nh hat ca phe, bao tng nhieu, tren nen mo em si.
Cac am te bao u tao thanh am ac, co cac long nho rai rac cha chat bat mau ai toan. U
Brenner thng phoi hp vi cac u khac, thng gap nhat la vi u boc dch nhay lanh tnh. (Hnh
38)
Hnh 38: U Brenner co gii han ro, mau vang nhat (A); am te bao u giong te bao chuyen tiep, co hoc nho
cha dch.
B. U TE BAO MAM (germ cell tumors):

U te bao mam chiem 15- 20 % cac u buong trng; a so la u lanh; u te bao mam ac ch
chiem 3% tong so cac ung th buong trng. U xuat phat t cac te bao mam nguyen thuy a b
chuyen dang (trong thi ky phoi thai, cac te bao nay di chuyen t thanh ben tui noan hoang en
mao sinh duc vao tuan le th 6). U te bao mam gom nhieu loai khac nhau tuy theo hng va
mc o biet hoa cua te bao mam nguyen thuy: theo hng noan nguyen bao th co u nghch
mam (te bao u giong noan nguyen bao); theo hng te bao phoi nhng mc o biet hoa con rat
kem th co carcinom phoi; te bao phoi co the biet hoa them na theo hng mo ngoai phoi tao
thanh u tui noan hoang va carcinom em nuoi, hoac theo hng mo trong phoi tao thanh u quai,
nh trong s o di ay.
1. U nghch mam (dysgerminoma):

Tng ng vi u tinh bao tinh hoan. U chiem 2% cac ung th buong trng va 50% u ac
cua te bao mam.Tuoi mac benh thng gap la 10-30 tuoi.
Hnh thai ton thng:
- ai the: u thng mot buong trng (80-90%), ac, mat cat mem t, trang vang en
xam hong.
-Vi the: te bao u ong dang, nhan tron nam chnh gia vi 1 hoac nhieu hach nhan; bao
tng nhieu, sang; te bao xep thanh am hoac be, ngan cach nhau bi cac dai si collagen
tham nhap nhieu limpho bao. (Hnh 39)
ieu tr bao gom phau thuat phoi hp vi xa tr va va hoa tr. U rat nhay vi xa va hoa nen
t le song them 5 nam van co the at en 80% cho du phat hien giai oan muon.
Hnh 39 : U nghch mam ac, mau xam hong. B : am te bao u va dai si tham nhap limpho bao.
2. U quai (teratoma):
U cau tao bi nhieu thanh phan xuat phat t ca 3 la phoi do te bao mam biet hoa theo
hng mo trong phoi. Phan biet 3 nhom u quai sau: u quai trng thanh lanh tnh, u quai trng
thanh hoa ac, u quai cha trng thanh.
a/ U quai trng thanh (mature teratoma):
La loai u te bao mam thng gap nhat, chiem khoang 58% cac u lanh cua buong trng.
Hau het u quai trng thanh co dang nang. Co the gap bat c o tuoi nao, nhng thng nhat
la nhom tuoi hoat ong sinh duc. Dang u ac t gap, chu yeu nhom benh nhan tre < 20 tuoi.
U co 2 buong trng trong 10-15% trng hp; co 1% b chuyen dang ac tnh goi la u
quai trng thanh hoa ac.
Hnh thai ton thng:

ai the: u co kch thc trung bnh 15 cm, dang nang, be mat lang, cha toc va chat ba.
Not ac trong nang cha mo m, rang, xng, nho vao trong long nang.
Vi the: u gom nhieu thanh phan mo khac nhau xuat phat t 3 la phoi, tat ca eu trng
thanh: bieu mo lat tang vi cac phan phu cua da nh nang long, tuyen ba, tuyen mo hoi, bieu
mo ho hap, bieu mo tieu hoa, m, sun, xng, tuyen giap, mo than kinh em, v.v. (Hnh 40)
Hnh 40: U quai trng thanh co long toc, mo m va rang (A); tren vi the co co mo sun (1), mo than kinh
em (2), bieu mo ho hap (3) (B)
b/ U quai trng thanh hoa ac (teratoma with malignant transformation):

Khoang 1% u quai trng thanh hoa thanh ac tnh. U co cau tao tng t u quai trng
thanh nhng co mot thanh phan chuyen thanh ac tnh, nh carcinom (thng gap nhat la
carcinom te bao gai) hoac sarcom.
c/ U quai cha trng thanh (immature teratoma):
Chiem 3% cac u quai cua buong trng, 1% cac ung th buong trng va 20% cac u te bao
mam ac. Tuoi mac benh trung bnh la 18 tuoi, t gap phu n ln tuoi.
Hnh thai ton thng:
- ai the: u co kch thc ln, trung bnh 18 cm, ac, mat cat nh tht, hoac co nhieu nang
nho, nhieu vung hoai t xuat huyet.
- Vi the: U gom nhieu thanh phan mo khac nhau xuat phat t ba la phoi. Thanh phan cha
trng thanh thng gap nhat la mo than kinh non (cac ong than kinh non); ngoai ra con co the
gap mo m, sun, xng cha trng thanh, nguyen bao c van, v.v. Phan o ac tnh cua u quai
cha trng thanh thng da vao so lng thanh phan mo than kinh non nhieu hay t. (Hnh 41)
Hnh 41: Mat cat u quai cha trng thanh cho thay ket hp mo ac va boc (A); Tren vi the co mo than kinh
non vi cac ong than kinh non (1), mo sun non (2) (B); Mot ong than kinh non phong ai ln (C)
3. U tui noan hoang (Yolk sac tumor):

U tuy hiem gap nhng la loai u ac te bao mam ng hang th 2, ch sau u nghch mam.
Thng gap nhat la tuoi 10-20 tuoi. Benh nhan co ham lng alpha - fetoprotein (AFP) trong
mau cao do te bao u san xuat.
Hnh thai ton thng:
- ai the: kch thc trung bnh cua u la 15 cm. U mot buong trng, vo bao ro, be mat
trn lang, mat cat ac, rai rac co cac boc va o xuat huyet.
- Vi the: hnh anh ac trng la cac te bao u hnh vuong hoac det xep thanh cac cau truc
dang ong hoac phu len cac nhu lien ket co cha mao mach gia. Cac nhu nay co the tho vao
trong long cac ong tren, goi la the Schiller Duval. (Hnh 42)
Hnh 42: U tui noan hoang ac, vo bao ro, co xuat huyet va thoai hoa boc (A) ; cau tao vi the cho thay
the Schiller - Duval (mui ten, B).
4. Carcinom em nuoi (choriocarcinoma):

U hiem gap, chiem <1% cac u te bao mam; thng gap di dang phoi hp vi cac u te
bao mam khac. Tuoi mac benh thng gap la trong 3 thap nien au. phu n trong giai oan
sinh e, can phan biet vi carcinom em nuoi co lien he vi thai ky, t t cung di can len. Benh
nhan co ham lng HCG trong mau rat cao do te bao u san xuat.
Hnh thai ton thng:
- ai the: u co kch thc ln 4-25 cm, xuat huyet hoai t, mot buong trng.
- Vi the: u gom cac n bao nuoi va hp bao nuoi d dang tng t nh carcinom em
nuoi xuat phat t nhau thai (Xem tren).
Khac vi carcinom em nuoi xuat phat t nhau thai, carcinom em nuoi cua buong trng
co tien lng xau hn, thng khong ap ng vi hoa tr thong thng va co t le t vong cao.
5. Carcinom phoi (embryonal carcinoma):
U hiem gap, ch chiem khoang 3% u te bao mam cua buong trng; thng gap ngi
tre, tuoi trung bnh la 15 tuoi. U co kch thc ln, trung bnh 17 cm va 1 buong trng. U co mat
o chac, mat cat vang nau, thng co xuat huyet va hoai t. Cau tao vi the tng t carcinom
phoi tinh hoan, gom cac te bao rat non xep thanh am hoac lot nhng khoang giong tuyen (Xem
carcinom phoi chng benh ly sinh duc nam).
C. U MO EM - DAY SINH DUC (sex cord - stromal tumours):

U xuat phat t day sinh duc hoac mo em cua tuyen sinh duc nguyen thuy. U chiem 10%
cac u buong trng, gom nhieu loai khac nhau t lanh en ac, co the biet hoa theo hng cac
cau truc cua n (te bao hat va vo) hoac cua nam (te bao Leydig - Sertoli). Thng gap nhat la:
1. U si (fibroma)
La u mo em thng gap nhat, chiem 4% cac u buong trng. U lanh, thng gap la
tuoi quanh man kinh. ai the u ac, chac, mau trang. Vi the u gom cac te bao hnh thoi giong
nh nguyen bao si xep thanh cac bo. (Hnh 43)
Hnh 43: U si co mat cat ac, trang (A), te bao hnh thoi xep thanh bo (B).
2. U te bao vo (thecoma):
La u lanh, thng gap tuoi man kinh. Trong nhieu trng hp, u tiet ra hormon estrogen
hoac androgen. phu n cha man kinh, u tiet ra estrogen co the gay roi loan kinh nguyet. U
thng phoi hp vi u si, goi la u si - vo. U te bao vo ac, mat cat mau vang, kch thc 5-10
cm. Tren vi the, u cau tao bi cac te bao vo hnh thoi, co nhan bau duc, bao tng sang do co
khong bao cha lipid. (Hnh 44)
Hnh 44: U te bao vo,mat cat ac, mau vang (A); te bao u hnh thoi, bao tng co khong bao cha lipid (B)
3. U te bao hat (granulosa cell tumor):

Chiem khoang 5% u buong trng, thng xay ra phu n a man kinh. U te bao hat la u
ac vi o ac tnh thap v co kha nang tai phat va lan tran tai cho. Trong 3/4 trng hp, u san
xuat ra estrogen, gay tang san noi mac t cung.
Hnh 45: U te bao hat ac, mau vang nau, co cho hoa boc (A); The Call - Exner (mui ten, B).
- ai the: u thng mot buong trng, kch thc thay oi 5-10 cm, co vo boc. Mat cat
mau vang, co cho hoa boc.
- Vi the: u cau tao bi cac te bao nho, hnh vuong hoac a giac, hp thanh cac dai hoac
am ac. Trong mot so trng hp, co the tm thay cac cau truc dang tuyen ac trng cho loai u
nay, goi la the Call Exner.
4. U te bao Sertoli - Leydig

U xuat phat t cac te bao mo em cua tuyen sinh duc nguyen thuy nhng do mot c che
cha ro, lai biet hoa theo hng nam gii. U co the gap moi la tuoi, thng gay ra trieu chng
nam hoa nh chng ram long, ph ai am vat, bien oi giong noi. ay la mot loai u co tiem nang
ac tnh, co the cho di can hoac tai phat trong mot so t trng hp.
Hnh thai ton thng:
- ai the: u co dang ac, 1 buong trng, mat cat mau vang.
- Vi the: u cau tao bi cac te bao giong te bao Sertoli va te bao Leydig. Tuy theo mc o
biet hoa tot hoac kem, chung co the ket hp thanh cau truc dang ong hoac thanh cac am ac
tng t sarcom. (Hnh 46)
Hnh 46: U te bao Sertoli - Leydig ac, mat cat mau vang (a); te bao Sertoli xep thanh ong (1),
chen gia la cac am te bao Leydig vi bao tng nhieu ai toan (2) (B) .
II. U DI CAN
U di can en buong trng (theo xuat o giam dan) thng t ung th ai trang, ung th
vu, limphom, u carcinoid va ung th da day. U Krukenberg la mot ung th buong trng do di can
t ung th ng tieu hoa: ca hai buong trng eu b xam nhap bi cac te bao ung th tuyen tiet
nhay dang mat nhan. (Hnh 47)
Hnh 47: U Krukenberg do di can t ung th da day, co dang boc, nhay (A); Te bao tuyen dang mat nhan
di can, xam nhap vao mo buong trng (mui ten, B).
LIEN HE LAM SANG
Ve xuat o, ghi nhan ung th tai Tp.HCM va Ha noi gan ay (2004-2008) cho thay ung
th buong trng xep hang th 6 va th 8 trong 10 loai th thng gap gii n. Benh nhan luc
c chan oan co tuoi trung bnh la 55 tuoi. My ung th buong trng ng hang th 4 va la
loai ung th phu khoa gay t vong hang au.
Cac yeu to lam tang nguy c gom co ung th buong trng co tnh gia nh (chiem khoang
5% ung th buong trng, phu n trong cac gia nh nay co nguy c ung th buong trng cao hn
bnh thng); tnh trang khong co con.
Ung th buong trng giai oan au khong co trieu chng hoac trieu chng khong ac hieu
nh roi loan kinh nguyet, xuat huyet am ao bat thng, tao bon, roi loan tieu tien. Khi r thay u
th thng a tre, u qua ln, pha v vo bao va co the a di can vao khoang bung.
Chan oan da vao tham kham phu khoa va sieu am, CT e anh gia khoi u vung chau
va s lan tran cua u trong o bung; nh lng cac chat anh dau u nh CA-125, HCG va AFP e
co hng phan biet gia cac loai u buong trng.
Xep giai oan lam sang tuy theo mc o lan rong cua u ac, gom 4 giai oan:
- Giai oan 1: u con gii han buong trng, cha pha v vo bao.
- Giai oan 2: u bat au an lan vao cac c quan lan can vung chau nh t cung, voi
trng.
- Giai oan 3: u lan ra ngoai vung chau, di can vao mac noi va cac hach sau phuc mac,
hanh ben.
- Giai oan 4: u a cho di can xa en phoi, gan
T le benh nhan c phat hien giai oan 1, 2, 3, 4 lan lt la 15%, 15%, 65%, 5% vi t
le song them 5 nam tng ng la 80%, 60%, 30%, 5%. Nh vay, a so benh nhan c phat
hien khi u a lan rong, gay kho khan cho ieu tr va anh hng en tien lng song con.
Ung th buong trng c ieu tr bang phau thuat cat bo u cung vi t cung va 2 phan
phu, ket hp vi xa tr va hoa tr .

1. Condylom am ho, am ao, co t cung luon co chung mot ac iem:
A/ Tang sng B/ Can sng C/ Nghch sng
D/ Tao nhu E/ Hien dien te bao rong lp be mat va trung gian
2. Benh nao co kha nang phat trien thanh carcinom te bao gai am ho sau nay:
A/ Nhiem HPV typ 16 B/ Lichen x hoa
C/ Viem am ho am ao do Candida albicans D/ A va B ung
E/ B va C ung
3. Khoi u dang chum, nhay nh thach: sa ra khoi am ao be gai di 5 tuoi, co the la:
A/ Viem am ao dang polyp B/ Carcinom te bao gai am ao
C/ Carcinom di can en am ao D/ Sarcom c van E/ Ton thng khac
4. Viem lo tuyen co t cung:

A/ Thng gap ngi a sinh e B/ Thng co chuyen san gai bieu mo co trong
C/ La ton thng tien ung D/ A va B ung E/ A va C ung.
5. Phet te bao hoc CTC c thc hien nh ky nham muc ch:

A/ Phat hien ton thng co t cung giai oan viem nhiem
B/ Phat hien sm nhng te bao khong ien hnh cua co t cung
C/ Phat hien ton thng tien ung cua co t cung
D/ Phat hien carcinom tuyen xam nhap co t cung
E/ Phat hien carcinom xam nhap co t cung
6. Tang san noi mac t cung co ac iem:

A/ Cau truc tuyen co the n gian hoac phc tap
B/ Trong tang san khong ien hnh, te bao tuyen tang san nhieu lp te bao, nhan to, chat
nhiem sac
tho, hach nhan ro, mat phan cc, ty le phan bao tang
C/ Tang san phc tap khong ien hnh co nhieu nguy c chuyen sang ung th
D/ Tang san noi mac t cung thng gap cac phu n tre tuoi
E/ Ch co A, B va C ung
7. Cac tuyen noi mac tang san xep sat nhau (au lng nhau), khong con thay mo em gia
cac tuyen, te bao tuyen d dang xep thanh dang nhu hay dang sang la hnh anh cua:
A/ Tang san n gian B/ Tang san phc tap
C/ Tang san khong ien hnh D/ Carcinom noi mac t cung
8. Mot phu n 23 tuoi, co thai 15 tuan th b say thai t nhien. Thai nho hn tuoi thai, gii tnh n;
nhau co mot so gai phu nh chum nho ben canh cac gai nhau bnh thng. Thai n nay se co bo
nhiem sac the la :
A/ 46XX B/ 69XXX C/ 45X D/ 23X E/ 47XXX
9. Phat bieu nao KHONG UNG ve benh te bao nuoi thai ky:
A/ Nhau nc toan phan gom toan cac long nhau ph ai, phu ne, thoai hoa nc
B/ Nhau nc ban phan gom cac long nhau thoai hoa nc va long nhau bnh thng
C/ Nhau nc xam nhap co cac long nhau thoai hoa nc xam nhap lp c trn t cung
D/ Carcinom em nuoi co long nhau thoai hoa nc va cac nguyen bao nuoi ac tnh
E/ Carcinom em nuoi la u ac tnh xuat phat t te bao nuoi co lien quan thai ky
10. Loai U buong trng lam tang ham lng HCG trong mau:
A/ U tui noan hoang B/ Carcinom em nuoi C/ U te bao hat
D/ U te bao si E/ Carcinom phoi
11. Mot u buong trng 10 cm, xe ra la 1 nang cha dch trong, vach nang trn lang co t choi sui
nh bong cai; vi the vung choi sui co hnh anh tao nhu phu bieu mo tru thap, tang san nhieu lp
nhng khong xam nhap mo em. Chan oan nao sau ay phu hp nhat:
A/ U boc dch trong lanh tnh B/ U boc dch nhay lanh tnh
C/ U boc dch trong giap bien ac D/ U boc dch nhay giap bien ac
E/ U boc dch trong ac tnh
12. Trong so u te bao mam buong trng, loai nao thng gap nhat :
A/ Carcinom em nuoi B/ U xoang noi b phoi C/ Carcinom phoi
D/ U nghch mam E/ U quai
Benh ly tuyen vu 239
BENH LY TUYEN VU
Muc tieu:
1. Ke ten cac benh ly viem thng gap cua tuyen vu
2. Mo ta va phan tch cac hnh thai bien oi si boc tuyen vu.
3. Mo ta va phan tch cac u lanh tuyen vu
4. Neu cac ac iem dch te, lam sang va giai phau benh cua carcinom tuyen vu.
Nhac lai ve mo hoc tuyen vu
Hnh 1: Cau tao mo hoc cua tuyen vu: S o cau tao tuyen vu bnh thng (A); Tuyen vu ngi trng
thanh: he thong ong dan (mui ten) va cac tieu thuy (*) (B). Cac n v tieu thuy ong tan (cac tieu
thuy vu); ong tan nho (mui ten); mo em trong tieu thuy (*) (C); Ong tan nho c lot lp te bao bieu
mo ben trong (*) va te bao c bieu mo ben ngoai (mui ten) (D).
Tuyen vu ngi phu n trng thanh co hnh giong nh na qua cam, c chia thanh
16 20 thuy giong nh cac mui cam, nhng thc ra gii han cua cac thuy khong ro rang va
thng chong lap len nhau. Moi thuy vu gom co nhieu tieu thuy va he thong ong dan, c bao
quanh bi mo em gian tieu thuy va mo m. Moi thuy vu m ra ben ngoai qua mot lo num vu.
He thong ong dan gom co ong thu thap o ra ngoai qua mot lo m tai num vu, ong nay phnh ra
tao xoang sa di num vu, tiep sau o la ong dan ln. Ong dan ln phan nhanh thanh nhng
ong dan nho hn va tan cung bang ong tan ngoai tieu thuy (Hnh 1A). n v tieu thuy ong tan
con goi la tieu thuy vu, ong tan ngoai tieu thuy khi vao trong tieu thuy c goi la ong tan trong
tieu thuy. Ong tan trong tieu thuy se phan nhanh thanh mot chum ong tan nho la nhng
ong tt au, con c goi la cac tui tuyen che tiet sa trong giai oan co thai va cho con bu. Cac
ong tan nho nam trong mot mo em trong tieu thuy, la mot mo lien ket giau te bao va chat can
ban nhng t si collagen, khac biet vi mo em ngoai tieu thuy (mo em gian tieu thuy) giau si
collagen va ngheo te bao. Ong tan nho c lot bi hai loai te bao, lp te bao bieu mo ben
trong va te bao c bieu mo ben ngoai. (Hnh 1BCD)
a so cac benh ly tuyen vu eu xuat phat t n v tieu thuy ong tan, ch mot so t
benh xuat phat t nhng ong dan ln, v du nh u nhu trong ong dan sa. (Hnh 2)
Hnh 2: S o v tr xuat phat cac benh ly tuyen vu thng gap

I. VIEM TUYEN VU (Mastitis):
Tng oi t gap.
1. Viem tuyen vu cap tnh va ap xe vu
Viem tuyen vu cap tnh thng gap nhat la nhng ngi ang cho con bu. Vi khuan
xam nhap vao mo vu qua cac khe nt num vu. Ngoai thi ky cho con bu, vi khuan co the xam
nhap qua cac ton thng san co da num vu (nh cham), gay viem tuyen vu cap tnh. Tac nhan
gay benh thng gap nhat la Staphylococcus aureus; Streptococcus t gap hn.
Hnh 3: Viem tuyen vu cap tnh ngi cho con bu: Bach cau a nhan trung tnh tham nhap cac ong tuyen
vu (mui ten, A), hnh thanh o ap xe (B).
Hnh thai ton thng: Viem tuyen vu cap tnh thng xay ra mot ben vu. Vu sng to,
nong, o, au, khi a ap xe hoa th co cam giac phap pheu khi s nan . Vi the la hnh anh ien
hnh cua viem cap tnh : sung huyet, phu viem va tham nhap bach cau a nhan (Hnh 3). Nhiem
Staphylococcus tao mot vung viem cap tnh khu tru; Streptococcus th co khuynh hng gay
nhiem trung lan toa toan bo vu.
Lien he lam sang : ieu tr bang khang sinh va rach dan lu o ap xe neu co.
2. Gian ong dan sa (Duct ectasia):
Gap phu n 50 60 tuoi, sanh nhieu lan
Benh sinh khong ro. Ong dan sa chnh b gian do cha ay chat tiet b co ac. Ong co
the b v gay phan ng viem vo khuan.
Hnh thai ton thng: Ong dan
sa gian, long ong cha ay cac manh
hoai t bat mau ai toan, chu yeu la cac
ai thc bao cha lipid trong bao tng
(bot bao). Bieu mo lot ong tuyen b teo
mong va hoai t (Hnh 4). V ong gay
phan ng viem man tnh mo tuyen vu
quanh ong tuyen : tham nhap nhieu
limpho bao, mo bao va oi khi rat nhieu
tng bao (nen con c goi la viem
tuyen vu tng bao).
Lien he lam sang: Ton thng
gay x hoa, lam co keo da va keo tut
num vu, co the gay nham lan vi ung
th vu. Tren nhu anh, cac o voi hoa do
lang ong canxi long ong cung co the
Hnh 4: Gian ong dan sa.
lam nham lan vi ung th.
3. Hoai t m (Fat necrosis):

t gap.
Benh nhan thng co benh s chan thng, phau thuat hoac xa tr vao tuyen vu.
Hnh thai ton thng : Khi au, trung tam ton thng la cac te bao m hoai t, bao
xung quanh co cac ai thc bao cha lipid (bot bao) va bach cau a nhan trung tnh (Hnh 5).
Sau o co tnh trang tang san si, mach mau va tham nhap limpho bao. Cuoi cung ton thng
se c thay the bang mo si.
Lien he lam sang : ton thng mot ben vu, chac, khong au, gii han khong ro. X hoa
gay co keo da lam nham lan vi hnh anh cua ung th.
Hnh 5: Hoai t m
4. Viem lao vu:
Hiem gap. Co the nguyen phat hoac th phat do phat tan vi khuan lao theo ng bach
huyet t hach co, trung that; hoac xam nhap mo vu t nhng o viem lao vung ke can.
Hnh thai ton thng : tren ai the thay nhng vung hoai t ba au; vi the co hnh anh
cac u hat lao.(xem hnh 26, chng viem va sa cha)
Lien he lam sang: Ton thng oi khi gay nham lan vi ung th, nhat la khi co kem hach
to (50% trng hp).
II. BIEN OI SI BOC (Fibrocystic change):
Bien oi si boc la ton thng thng gap nhat cua tuyen vu, nh tuoi mac phai t
khoang 30 tuoi en trc tuoi man kinh. Ch 10% phu n co ton thng phat hien c tren lam
sang. Nhng khi lam t thiet, co en 60-90% phu n co ton thng nay ma khong co bieu hien
lam sang.
Benh sinh lien quan vi tnh trang mat can bang hormon: tang qua mc estrogen hoac
thieu hut progesteron. Thuoc nga thai uong co the lam giam nguy c mac ton thng nay (do
cung cap mot nguon estrogen va progesteron can oi).
Bien oi si boc co 3 hnh thai bien oi mo hoc: (1) Tao boc (thng co chuyen san nh
tiet i kem) va hoa si; (2) Tang san bieu mo; va (3) Benh tuyen.
Mot so hnh thai ton thng trong bien oi si boc co lien quan vi tang nguy c ung th
vu
Da tren mc o lam tang nguy c b ung th vu, co the chia cac bien oi si boc thanh
2 nhom chnh: (1) Bien oi si boc khong tang sinh (Nonproliferative fibrocystic change) va (2)
Bien oi si boc co tang sinh (Proliferative fibrocystic change).
Hnh 6: Bien oi si boc tuyen vu: Khong tang sinh (A); Co tang sinh (B)
1. Bien oi si boc khong tang sinh: Khong lien quan vi tang nguy c ung th vu. La hnh
thai bien oi thng gap nhat trong bien oi si boc tuyen vu.
Vung ton thng gii han khong ro, mat o chac hn mo tuyen vu bnh thng; hoac ton
thng la mot boc ln, gii han ro, mat o cang.
Hnh thai ton thng: ton thng ac
trng cua bien oi si boc khong tang sinh la tao
boc va hoa si.
- ai the: Co the la mot boc ln, ng
knh at en 5 cm; nhng thng la nhieu boc nho
nam ca hai ben vu. Ben trong boc cha chat
dch vang uc hoac trong. Khi co xuat huyet cu
trong boc, nhn ben ngoai boc co mau nau xanh.
Chat tiet trong long boc co the b lang ong canxi
tao ra hnh anh cac o voi hoa nho thay c tren
nhu anh. Gia cac boc la mo si va m.
- Vi the: Boc lot bieu mo vuong hay tru.
Mot so trng hp, te bao bieu mo tang san nhe,
chong chat len nhau (nhng khong vt qua 4 lp
te bao) hoac tao nhu nho vao long boc. boc ln, Hnh 7: Mo si va cac boc kch thc khong eu.
lp bieu mo lot b ep det. Te bao lot boc co the chuyen san nh tiet (te bao tr nen hnh a
dien; bao tng nhieu, bat mau ai toan, co hat; nhan tron nho am mau); loai boc nay hau nh
luon lanh tnh. Xung quanh boc la mo si ac, khong con giong vi mo em trong tieu thuy
na.(Hnh 8, 10A)
Hnh 8: Bien oi si boc khong tang sinh, tao boc (1), hoa si (2), tang san bieu mo (3), tang san so lng
ong tuyen (4) (A); Te bao lot vach boc chuyen san nh tiet (B).
2. Bien oi si boc co tang sinh: Co lien quan vi tang nguy c ung th vu. La ton thng co
tang sinh bieu mo, thng xay ra tren nen cua mot bien oi si boc khong tang sinh.
Tang sinh bieu mo bao gom: (1) Benh tuyen: la tnh trang gia tang so lng tui tuyen
trong tieu thuy, lam tieu thuy gian rong ra va bien dang; (2) Tang san bieu mo: gom tang san
ong: la tnh trang gia tang so lng te bao bieu mo trong ong tan lam ong gian ln; va tang san
tieu thuy la tnh trang tang sinh cac te bao nho eu ket dnh nhau long leo, lap ay va lam gian
rong mot so tui tuyen trong tieu thuy.
a. Benh tuyen (Adenosis): Benh tuyen x cng la dang giai phau benh thng gap nhat
cua benh tuyen. Dang nay co y ngha quan trong v hnh thai ton thng tren vi the va nhu anh
oi khi rat giong mot carcinom.
Hnh thai ton thng:
+ ai the : Vung ton thng cng chac, gii han khong ro.
+ Vi the: Cau truc tieu thuy van con, so lng ong tuyen (ong tan) tang len t nhat gap
hai lan bnh thng. Ong tuyen c lot bi hai lp te bao (bieu mo va c bieu mo). Mo em si
tang san, hyalin hoa, ep det va lam meo mo cac ong tuyen vung trung tam ton thng. vung
ngoai vi, cac ong tuyen lai dan rong. oi khi x hoa nang, ong tuyen b ep det thanh nhng day
te bao co the nham vi carcinom ong tuyen vu. Voi hoa vi the trong long ong co the gay nham
vi ung th tren nhu anh. (Hnh 9)
Hnh 9: Ton thng benh tuyen gii han khong ro (A); Tieu thuy dan rong do tang so lng ong tuyen (B).
b. Tang san bieu mo:

Hnh thai ton thng :
- ai the la mot vung mo vu day len, gii han khong ro.
- Vi the :
* Tang san ong: gom tang san ong thong thng va tang san ong khong ien hnh.
+ Tang san ong thong thng (Usual ductal hyperplasia):
Tang san va: bieu mo tang san tao cau noi trong long ong
Tang san nang: long ong gian, lap ay te bao tang san, nhng van con nhng
khoang trong khong tron eu, meo mo, chen gia cac te bao.
Te bao tang san khong co hnh anh bat thng: dan so te bao a dang, van con lp te
bao c bieu mo ben ngoai. Te bao bieu mo tang san co hach nhan khong ro, co khuynh hng
xep song song nhau, phan bao rat t; trng hp tao cau noi, te bao co truc song song vi truc
cua cau noi. (Hnh 10 B va C)
+ Tang san ong khong ien hnh (Atypical ductal hyperplasia): Ton thng gii han ch
mot t ong tuyen; ton thng co nhieu ac iem nhng cha u e chan oan mot carcinom ong
tuyen vu tai cho grad thap: te bao nho, ong dang, nhan tron phan bo eu an, lap ay long
ong hoac tao cau noi, tao sang co kch thc ong eu; nhng trong ong van con mot dan so te
bao th hai tng t nh nhng te bao trong tang san ong thong thng. (Hnh 10D)
C D
Hnh 10:Bien oi si boc khong tang sinh: Tang san nhe bieu mo (A);
Bien oi si boc co tang sinh: Tang san va (B),Tang san nang (C),Tang san khong ien hnh (D).
* Tang san tieu thuy:

ay, chung ta ch noi en tang san tieu thuy khong ien hnh. ay la mot thc the co
hnh thai mo hoc va dien tien sinh hoc khac han tang san ong, vi nguy c dien tien thanh
carcinom tieu thuy xam lan tang gap 5 lan bnh thng. Trong tang san tieu thuy khong ien
hnh ch co di 50% ong tan (hoac tui tuyen) trong tieu thuy b gian rong, lap ay bi cac te
bao ong dang, nhan tron nhat mau, hach nhan nho. Te bao ket dnh nhau long leo, sap xep
khong nh hng, con khoang trong gia cac te bao. (Hnh 11)
Hnh 11: Tang san tieu thuy khong ien hnh: <50% so ong trong tieu thuy b dan rong, cha ay te bao (A);
Ong trong tieu thuy dan rong cha ay te bao ong dang, nhan tron (B).
Lien he lam sang: Bien oi si boc la nhng thay oi cua mo vu theo tuoi tac hau nh
khong can phai ieu tr; tuy nhien van phai lu y rang no co the lam tang nguy c ung th vu.
Bien oi si boc khong tang sinh co hoac khong kem tang san nhe bieu mo ong tuyen vu th
khong lam tang nguy c; nhng bien oi si boc co tang sinh gom benh tuyen x cng hoac
tang san ong thong thng lam nguy c tang 1,5 - 2 lan; tang san ong hoac tieu thuy khong
ien hnh lam nguy c tang 4 - 5 lan. Nhng trng hp tang nguy c nay can c theo doi
nh ky, chup nhu anh va cho sinh thiet choc hut khi can thiet.
III. U
1. U si tuyen vu (Fibroadenoma):
La u lanh tuyen vu thng gap nhat. Do tang san ca hai thanh phan mo em va bieu mo
tuyen. Co the gap moi la tuoi trong giai oan hoat ong sinh duc, nhng thng nhat la trc
30 tuoi.
- ai the : U tron, mat o chac, gii han ro, di ong tot, kch thc co the t 1 cm en
tren 10 cm, trung bnh la 2-4cm. Mat cat u phong, ong nhat, mau trang xam.
Hnh 12: U si tuyen gii han ro, mat cat trang phong (A); Mo em trong tieu thuy tang san lam keo dan va
ep det cac ong tuyen (B).
- Vi the: mo em tha trong tieu thuy tang san co nhieu nguyen bao si, chat nen dang
niem, bao quanh cac ong tuyen. Ong tuyen tron nho, co cho dan tao nang nho (goi la u si
tuyen quanh ong) hoac b mo em ep det, keo dai va phan nhanh (goi la u si tuyen trong ong).
Lien he lam sang : Do bieu mo ong tuyen ap ng vi bien oi noi tiet to trong c the, u
si tuyen co the tang nhe kch thc trong na sau cua chu ky kinh, trong thai ky. U khong t
thoai trien va hiem khi hoa ac.
2. U diep the (Phyllodes tumor):
t gap hn u si tuyen. Tuoi mac benh ln
hn tuoi cua u si tuyen, trung bnh la 50 tuoi. U
do tang san thanh phan mo em trong tieu thuy,
ket hp vi thanh phan bieu mo tuyen lanh tnh. U
diep the gom 2 loai: u diep the lanh va u diep the
ac.
Hnh thai ton thng :
- ai the: u diep the lanh va diep the ac
co hnh anh ai the giong nhau. U tron, nhieu
thuy, gii han tng oi ro. Kch thc trung bnh
khoang 5cm. U co the rat ln, chiem toan bo mot
ben vu, da tren u cang bong. (Hnh 13A)
Mat cat u mau trang xam, ac, co nhng
khe ranh lam u co hnh anh nh cai la; oi khi u
Hnh 13 A: U diep the vu
hoa boc vi nhng not choi dang nhu. (Hnh 13B)
Hnh 13B: U diep the lanh co nhieu khe ranh nh hnh cai la (A); co khi hoa boc vi nhieu not choi nhu (B);
U diep the ac co vung hoai t xuat huyet (C).
- Vi the:
+ U diep the lanh co cau truc va t le mo em / tuyen tng t nh cua u si tuyen,
nhng mo em cua u giau te bao hn nhieu. (Hnh 14)
+ U diep the ac : thanh phan mo em co hnh anh giong nh sarcom, rat giau te bao,
nhieu phan bao, d dang te bao, xam lan vao mo ke can. Thanh phan bieu mo tuyen van lanh
tnh.
Hnh 14: U diep the lanh co khe ranh nh hnh cai la, cau tao bi thanh phan mo em va tuyen tang san (A);
U diep the ac co mo em giong sarcom, nhieu phan bao (mui ten), (B).
Lien he lam sang: oi vi u diep the lanh, ch can ieu tr cat u. U co khuynh hng tai
phat tai cho neu cat khong u rong e sot mo u. U diep the ac hay tai phat, va khoang 12% cac
trng hp cho di can xa (phoi, xng). ieu tr u diep the ac bao gom oan nhu nhng khong
can thiet phai nao hach nach.
3. U nhu trong ong sa (Intraductal papilloma):
U lanh tnh, thng gap ong dan sa chnh hay trong xoang sa. Tuoi mac benh la phu
n trung nien hoac ln tuoi hn. oi khi u gay tiet dch - mau num vu.
- ai the: U n oc, nam ngay di quang vu, ng knh < 1cm.
- Vi the: U nam trong ong dan sa chnh b gian hoac trong xoang sa. U phat trien tao
nhieu nhu co truc lien ket mach mau, phu ben tren la hai lp te bao bieu mo va c bieu mo.
Thng co hien tng chuyen san nh tiet te bao bieu mo.
Hnh 15: U nhu trong ong sa (A); U tao choi nhu nho vao long ong (B).
4. Carcinom
Dch te hoc: Ung th vu la loai ung th thng gap nhat n gii tai cac nc Au My.
Tai Viet Nam, ay la loai ung th ng au gii n cua ca 2 mien Nam Bac theo so lieu thong
ke gan ay (2004-08) cua Ha noi va TP. Ho Ch Minh. T le t vong do ung th vu ch ng sau
ung th phoi. nh tuoi mac benh la 40-60 tuoi. Trong ung th vu, 99 % la carcinom, mot t le
nho con lai la cac sarcom nh sarcom mach mau, sarcom mo em, limphom vu, .
C che benh sinh: khong ro, nhng hien nay nhieu nghien cu ve lam sang va dch te
cho thay co mot so yeu to lien quan vi nguy c mac benh ung th vu n gii nh:
+Yeu to gia nh: co me, ch b ung th vu. Khi khao sat nhng trng hp nay, thay co
s lu hanh cac gen BRCA1 va BRCA2; nhng benh nhan nay co tuoi mac benh tre hn.
+ Tnh trang noi tiet : co kinh sm, man kinh muon, co con au long muon, sanh t con.
+ Tac ong cua moi trng: tan suat benh cac nc cong nghiep phat trien cao gap 4-
5 lan cac nc ang phat trien.
+ Tien can tiep xuc tia xa;
+ Co ton thng tang san bieu mo, nhat la tang san khong ien hnh.
Hnh thai ton thng:
+ Phan loai mo hoc :
A.Carcinom tai cho:
- Carcinom tieu thuy tai cho
- Carcinom ong tuyen vu tai cho
B. Carcinom xam nhap :
- Carcinom tieu thuy xam nhap (5-10%)
- Carcinom ong tuyen vu xam nhap :
+ Carcinom ong tuyen vu xam nhap dang khong ac hieu
(Not Otherwise Specified = N.O.S) (70-80%)
+ Carcinom ong tuyen vu xam nhap dang nhay (1-6%)
+ Carcinom ong tuyen vu xam nhap dang ong nho (2%)
+ Carcinom ong tuyen vu xam nhap dang tuy (1-5%)
C. Benh Paget cua vu
- ai the: u co the
co kch thc rat nho,
khong s thay, ch phat
hien c bang nhu anh
(nhat la trong carcinom tieu
thuy tai cho); thng vao
thi iem chan oan, u la
mot khoi co kch thc
khoang 2-3 cm, gii han
tng oi ro; mat o cng
chac; mat cat sng lom
do x hoa, lam tam vang.
(Hnh 16) Hnh 16: Carcinom vu. U gii han tng oi ro, mat cat sng, lom.
- Vi the :
a/ Carcinom tai cho:
* Carcinom tieu thuy tai cho: xuat phat t ong tan. Cau truc tieu thuy con gi c
nhng cac ong tan (tui tuyen) b bien dang do dan rong, lap ay bi cac te bao tang sinh
ong dang, kch thc hi ln hn bnh thng, nhan tron hay bau duc, hach nhan nho.
Cung co the thay cac te bao mat nhan co khong bao cha nhay trong bao tng. Neu khao
sat ca hai ben vu, co en 50-70% carcinom tieu thuy tai cho co ton thng ca hai ben vu.
Nguy c phat trien thanh ung th xam lan tang gap 10 lan so vi bnh thng. Phan biet vi
tang san khong ien hnh tieu thuy da tren cac yeu to: ton thng anh hng tren 50% cac
ong tan, va gia cac te bao khong con khoang trong. (Hnh 17)
Hnh 17: Carcinom tieu thuy tai cho, cau truc tieu thuy tng oi con nguyen ven
* Carcinom ong tuyen vu tai cho: Ton thng gii han trong long ong, mang ay
con nguyen, cha b pha v. Da tren cau truc, carcinom ong tuyen vu tai cho c chia
thanh 5 dang: ba kho, ac, sang, nhu va vi nhu. (Hnh 18)
- Carcinom tai cho dang ba kho: te bao u co o ac tnh cao, tang sinh nhanh chong; do
o cac te bao trung tam thng b hoai t va canxi hoa. Tren mat cat u, co the nhn
thay nhng vung lam tam chat hoai t giong nh chat ba mun trng ca.
- Carcinom tai cho dang ac va dang sang: te bao u co o ac tnh t thap en cao, lap
ay ong tuyen. Trong dang sang, gia am te bao u co nhng khoang trong tron eu va
phan bo eu an trong long ong.
- Carcinom tai cho dang nhu va vi nhu: te bao tang sinh tao nhu phc tap, ta tren
truc lien ket mach mau nhng khong co lp te bao c bieu mo trong dang nhu, hoac
khongco truc lien ket mach mau trong dang vi nhu
Hnh 18: Carcinom ong tuyen vu tai cho dang ba kho (A), dang sang (B), dang vi nhu (C)
Do cac dang cua carcinom ong tuyen vu tai cho thng ket hp vi nhau trong phan ln
cac trng hp va phan loai da tren hnh thai t co gia tr trong ieu tr va tien lng, ngay nay,
nhieu tac gia a a ra nhieu bang phan loai carcinom ong tuyen vu tai cho da tren grad mo
hoc cua u. Phan loai nay cho biet nguy c tai phat cua carcinom ong tuyen vu tai cho. Theo To
chc Y te the gii, carcinom ong tuyen vu tai cho c chia thanh 3 grad: (Hnh 19)
- Carcinom ong tuyen vu tai cho grad thap: Te bao nho, ong dang, nhan eu, hat nhan
khong ro. Te bao sap xep thanh cau truc dang sang, ac hoac vi nhu. Khong co hoai t trong
long ong.
- Carcinom ong tuyen vu tai cho grad trung bnh: Te bao nho ong dang, nhan eu, co
kem hoai t trong long ong; hoac te bao co nhan khong ien hnh mc o trung bnh, khong
kem hoai t.
- Carcinom ong tuyen vu tai cho grad cao: Te bao ln, nhan khong ien hnh, d dang,
hat nhan ro. Te bao xep thanh cau truc dang ac co kem hoai t trong long ong; hoac co khi ch
la mot lp te bao d dang lot long ong.
Hnh 19: Carcinom ong tuyen vu tai cho grad thap (A), grad trung bnh (B), grad cao (C)
B/ Carcinom xam nhap :
* Carcinom tieu thuy xam nhap (5-10%) : co the b ca hai ben vu, hoac co nhieu o
tren cung mot vu. Kinh ien, cac te bao u xep thanh cac day mot hang te bao, khong tao
ong hoac tao nhu, xam nhap trong mo em si. (Hnh 20)
Hnh 20: Carcinom tieu thuy xam nhap, te bao u tao thanh cac hang mot, bao quanh 1 ong tuyen vu bnh
thng (A) . Te bao u xam nhap, xep thanh day mot hang te bao (B).
* Carcinom ong tuyen vu xam nhap :

- Carcinom ong tuyen vu xam nhap dang khong ac hieu (Not Otherwise Specified,
N.O.S) : la dang thng gap nhat, chiem 70-80% carcinom xam nhap. Te bao u xep
thanh day, o ac, ong nho hoac nhieu am noi ket vi nhau xam nhap trong mo em.
Te bao u co kch thc thay oi, t nhng te bao nho co nhan tang sac trung bnh en
nhng te bao khong lo co nhan tang sac meo mo. Grad mo hoc cua u c anh gia
qua mc o khong ien hnh cua nhan te bao va kha nang thanh lap ong tuyen cua te
bao u. (Hnh 21)
Hnh 21: Carcinom ong tuyen vu xam nhap dang khong ac hieu (NOS), xam nhap vao mo m (A); xam
nhap vao mach bach huyet (B).
- Carcinom ong tuyen vu xam nhap dang nhay : Gap phu n ln tuoi hn, dien tien
cham trong nhieu nam, tien lng tot neu khong ket hp vi dang khac. Tren vi the thay
nhng ao te bao u hoac nhng ong tuyen nam trong nhng be nhay ln bat mau nhat.
(Hnh 22A)
- Carcinom ong tuyen vu xam nhap dang ong nho: gap phu n tuoi tre hn, mot t le
nho co u hai ben vu hoac nhieu o. Tren vi the te bao u xep thanh nhng ong nho, lot mot
lp te bao (khong co te bao c bieu mo), xam nhap trong mo em (phan biet vi ton thng
x cng lanh tnh, ong tuyen c lot bi hai lp te bao: bieu mo va c bieu mo). (Hnh
22B)
- Carcinom ong tuyen vu xam nhap dang tuy : Te bao u ln, nhan bong, a dang, co
hach nhan ro. Te bao u xep thanh cac am ac te bao, noi ket lai vi nhau; ong thi co rat
nhieu limpho bao tham nhap xung quanh am te bao u hoac xen ke gia cac te bao u.
(Hnh 22C)
Hnh 22: Carcinom ong tuyen vu xam nhap dang nhay (A), dang ong nho (B), dang tuy (C).
Grad mo hoc: la yeu to tien lng, lien quan vi song con cua carcinom tuyen vu xam
nhap. anh gia grad mo hoc da tren 3 yeu to: (1) Mc o thanh lap ong cua te bao u; (2) Mc
o d dang nhan cua te bao u; va (3) Ch so phan bao cua mo u.
C/ Benh Paget num vu: ai the la mot ton thng loet da num vu giong nh cham. Vi
the: te bao u nam trong lp bieu b cua num vu va quang vu. o la nhng te bao co kch thc
ln, nhan ln, bao tng nhieu va sang (con goi la te bao Paget), nam rai rac tng con hoac
thanh am. S xuat hien cua nhng te bao nay trong lp bieu b la do cac te bao ung th t mot
carcinom ong tuyen vu tai cho hoac xam nhap ben di i len. Tien lng benh Paget phu
thuoc vao ban chat cua khoi carcinom nam ben di. (Hnh 23).
Hnh 23: Benh Paget num vu, Ton thng loet da num vu giong nh cham (A); Te bao Paget nam trong lp
bieu b cua da num vu (mui ten) (B)
Lien he lam sang :

1. anh gia giai oan : co y ngha quan trong giup la chon phng phap ieu tr va tien
lng benh. c da vao yeu to T, N, M.
T N M
T0 : carcinom tai cho N0 : khong di can hach M0 : khong co di can xa
T1 : 2 cm N1 : di can hach cung ben, M1 : co di can xa
T2 : 2 5 cm di ong
T3 : > 5 cm N2 : di can hach cung ben,
T4 : Xam nhap thanh ngc dnh khoi
N3 : di can hach tren va
di on
2. Xep giai oan lam sang :

Giai oan I T1 N0 M0
Giai oan II T1-2 N1 M0
T3 N0 M0
Giai oan III T1-3 N1-2 M0
T4 N bat ky M0
T bat ky N3 M0
Giai oan IV T bat ky N bat ky M1
anh gia giai oan lam sang giup la chon phng phap ieu tr thch hp. Benh nhan
giai oan I, II se c phau thuat oan nhu nao hach trc, sau o hoa tr hoac xa tr bo tuc neu
thuoc nhom co nguy c cao (tuoi tre, grad mo hoc cao, nhieu hach di can,), t le song 5 nam
nhom benh nhan nay la 75-87%. oi vi giai oan III, IV, benh nhan se c hoa tr trc khi
phau thuat oan nhu nao hach, t le song them 5 nam cua nhom nay giam xuong con 12-46%.
3. Dien tien : U phat trien ln dan dnh vao can c sau thanh ngc; xam nhiem da lam co
keo va dnh da; xam nhiem lam nghen tac ng dan lu bach huyet cua da gay bien oi da
giong nh da cam; hoac lam tuyen vu sng to va o, con goi la ung th tuyen vu dang viem.
Ung th di can theo ng bach huyet theo nhieu hng, nhng thng nhat la vao
nhom hach nach va nhom hach doc ong mach vu trong. Di can xa theo ng mau en phoi,
xng, gan, thng than, nao, va mang nao.(Hnh 24)
4. Tien lng : phu thuoc rat nhieu yeu to :
- Tuoi : < 50 tuoi, tien lng tot hn. Nhng < 35 tuoi tien lng lai xau nh > 50 tuoi.
- Giai oan lam sang : giai oan cang sm tien lng cang tot
- Loai mo hoc : dang nhay va dang ong nho co tien lng tot hn
- Grad mo hoc : grad thap tien lng tot hn.
- Thu the estrogen va progesteron tren te bao u : dng tnh cho tien lng tot hn v
ap ng vi ieu tr noi tiet.
- Toc o tang trng cua te bao u cang cao, tien lng cang xau
- Mc o bieu hien cua cac gen sinh u va mat bieu hien cua cac gen c che u
- Va nhieu yeu to khac..
5. Cac xet nghiem dung trong chan oan ung th vu:
- Phng phap choc hut bang kim nho: khi co mot khoi s c vu, co the choc hut te
bao e chan oan tnh lanh ac cua u. Phng phap nay n gian, an toan, t ton kem; o
chnh xac cao co the thay the phng phap sinh thiet thng. (Hnh 25)
- Chup X quang tuyen vu (nhu anh) : giup phat hien nhng ton thng rat nho khong s
thay c (tam soat va phat hien sm u ac); hoac giup hng dan vung can lam sinh thiet
hoac phau thuat.
- Sinh thiet loi mo (core biopsy): oi vi nhng ton thng khong s thay c nh tren,
di s hng dan cua sieu am hoac X quang, co the dung 1 thiet b ac biet co gan kim ln
t 7-G en 14-G lay ra nhng loi mo (ng knh 2-5mm, dai 10-15mm) e khao sat vi the.
- Sinh thiet tc th (cat lanh) : thc hien trong luc phau thuat, cho ket qua sau vai
phut, danh cho nhng ton thng nghi ng ac tnh ma nhng phng phap tren cha khang
nh c.
Hnh 24: Cac v tr di can cua carcinom tuyen vu Hnh 25: Phng phap choc hut bang kim nho
BENH TUYEN VU NAM GII

1. N hoa tuyen vu (Gynecomastia):
Do mat quan bnh gia estrogen va androgen (estrogen c tao ra vo thng than),
gap vao giai oan day th hoac tuoi gia b suy chc nang tinh hoan, hoac ngi x gan
khong chuyen hoa c estrogen; hoac lien quan vi dung ru, ma tuy, thuoc tam than,
Hnh 26: N hoa tuyen vu ben trai (A); tang sinh ong tuyen vu ma khong tang sinh tieu thuy (B)
- ai the: mot hoac hai ben tuyen vu n to nh n day th

- Vi the: tang sinh ong tuyen vu nhng khong tang sinh tieu thuy, xung quanh la mo lien
ket tha tham nhap mot t limpho bao va tng bao.(Hnh 26)
2. Carcinom:
Rat hiem gap gii nam, chiem 1% cac ung th vu. U gay loet, xam nhiem da va thanh
ngc ben di. Vi the thng la loai carcinom ong tuyen vu. U di can xa vao phoi, nao, xng,
gan.
1. Mot phu n 40 tuoi co tiet dch lan mau num vu phai, trc tien nen ngh en :
A/ Viem tuyen vu cap tnh B/ U si tuyen tuyen vu C/ U nhu trong ong sa
D/ Benh tuyen tuyen vu E/ Benh Paget cua vu
2. Mot phu n 65 tuoi, vap te va ngc vao canh ca. Khi au ba thay mot dau sng bam 3 cm
tren tuyen vu ben trai, tan mat trong vai tuan sau. Nhng roi ba phat hien co mot khoi u chac
trong vu ngay di cho bam mau trc ay. Chan oan c ngh en nhieu nhat la:
A/ Carcinom ong tuyen vu tai cho B/ Carcinom ong tuyen vu xam nhap
C/ Hoai t m D/ Dan ong dan sa E/ Viem tuyen vu cap tnh ap xe hoa
3. Benh Paget num vu la :
A/ La mot ten goi khac cua benh cham num vu
B/ Vi the la hnh anh carcinom te bao gai cua da num vu
C/ a so trng hp la do te bao t mot ung th tuyen vu ben di theo cac ong dan
i len num vu
D/ ieu tr ch can cat rong quang vu num vu E/ Tat ca A, B, C, D eu ung
4. Trong bien oi si boc vu, khi bieu mo tang san tao cau noi trong long ong, mc o tang san
c anh gia la :
A/ Tang san ong tuyen mc o nhe B/ Tang san ong tuyen mc o va
C/ Tang san ong tuyen mc o nang D/ Tang san ong tuyen khong ien hnh
E/ Tang san tieu thuy khong ien hnh
5. Sinh thiet mot khoi u vu benh nhan n 34 tuoi. Tren vi the thay so lng cac ong tuyen tang
len gap nhieu lan. Cac ong lot bi hai lp te bao; mo em si ac giau si collagen tang sinh,
bop meo mo cac ong tuyen. Vung ke can co cac ong tuyen dan rong thanh boc, co ong lot bieu
mo chuyen san nh tiet. Chan oan nao sau ay la phu hp nhat ?
A/ Dan ong dan sa B/ Bien oi si boc tuyen vu C/ U si tuyen vu
D/ U diep the lanh E/ Carcinom tieu thuy tai cho
6. Benh nhan n, 22 tuoi, phat hien thay mot khoi u vu tren ngoai ben trai. Kham thay u co
ng knh 1,5 cm, gii han rat ro, mat o chac, di ong nhieu. Choc hut bang kim nho vao u,
thay nhieu te bao bieu mo va te bao c bieu mo tang san va nhieu am mo em giau chat can
ban. Chan oan c ngh en la:
A/ Nang vu B/ U si tuyen C/ U nhu trong ong
D/ Hoai t m E/ Carcinom tuyen vu
7. Chan oan xac nh mot u diep the ac da vao ac iem nao sau ay cua u:
A/ Co kch thc rat ln B/ Co xuat huyet hoai t
C/ Co hoa nang va nhieu choi nhu D/ Co thanh phan bieu mo giong carcinom
E/ Co thanh phan mo em giong sarcom
8. Trong phan loai mo hoc cua carcinom tuyen vu, ngi ta phan biet hai loai carcinom tieu thuy
va carcinom ong tuyen da tren s khac biet cua chung ve :
A/ Nguon goc xuat phat B/ Hnh anh vi the C/ Dien tien sinh hoc
D/ A, B, C ung E/ Ch B va C ung
9. Mot phu n 50 tuoi phat hien vai khoi u nho vu phai. Chup nhu anh phat hien nhieu ton
thng am o khong eu kch thc 0,5 1 cm ca hai ben vu. Choc hut bang kim nho cac ton
thng hai ben vu eu thay co te bao ac tnh, co cho xep thanh 1 hang te bao. Chan oan
c ngh en nhieu nhat la:
A/ U diep the ac B/ Carcinom ong tuyen vu xam nhap
C/ Carcinom tieu thuy xam nhap D/ Carcinom dang tuy
E/ Carcinom dang nhay
Benh Ly Tuyen Giap 255
BENH LY TUYEN GIAP
Muc tieu:
1. Ke ten 3 d tat bam sinh tuyen giap.
2. Mo ta va phan tch 4 loai viem tuyen giap.
3. Mo ta va phan tch 3 loai tang san tuyen giap
4. Mo ta va phan tch u tuyen tuyen giap dang nang.
5. Mo ta va phan tch 6 loai carcinom tuyen giap.
Trong thi ky phoi thai, mam tuyen giap c hnh thanh vao tuan le th 3, do s tang
sinh cua bieu mo noi b tai v tr tng ng vi lo tt goc li cua ngi ln. Mam tuyen giap
chui xuong theo ng gia co tao thanh ong giap li, i trc xng mong va kh quan e
en sun giap; tai ay no phat trien thanh tuyen giap gom 2 thuy noi nhau bang eo giap nam
ngay di sun nhan; phan tren cua ong giap li se b thoai hoa va bien mat vao tuan le th 6.
T tuan le th 9, xuat hien cac dai hoac am ac te bao nang giap, sang tuan le th 10 bat
au thay long nang va en tuan le th 14 th tuyen giap a gom cac nang giap hoan chnh vi
chat keo trong long nang (Hnh 1). Tuyen giap cua ngi trng thanh can nang khoang 15-35
gram, cau tao bi cac nang giap hnh cau ng knh 200 m. Nang giap c lot bi mot lp
te bao nang co hnh dang thay oi tuy theo mc o hoat ong; co the la hnh det, vuong hoac
tru thap; cac te bao nang san xuat thyroglobulin, T3 va T4, di s kiem soat cua TSH (thyroid
- stimulating hormone, con goi la thyrotropin) cua tuyen yen va TRH (thyroid hormone -
releasing hormone) cua vung di oi. Ngoai ra, nang giap con cha cac te bao than kinh noi
tiet, goi la te bao C, san xuat ra calcitonin; cac te bao nay co nguon goc t mao than kinh, en
tuyen giap qua trung gian cua the mang cuoi (ultimobranchial body).
Hnh 1: S hnh thanh va phat trien cua tuyen giap
Benh ly tuyen giap thng bieu hien ra bang tnh trang tuyen giap phnh to, lan eu ca 2
thuy hoac khong oi xng, co the tao ra mot hay nhieu cuc trong tuyen giap, hoac thanh mot
khoi u xam lan ra mo xung quanh. Chc nang tuyen giap van con bnh thng (goi la bnh
giap), hoac co tnh trang tang hay giam hoat ong (cng giap va nhc giap). Khong co moi
lien he n gian gia cac hnh thai ton thng vi hoat ong chc nang cua tuyen giap; th du
trong benh phnh giap a cuc, a so trng hp co bieu hien bnh giap nhng mot so t lai co
trieu chng cng giap hoac nhc giap.
Benh ly tuyen giap la loai thng gap, co the r thay 1 cuc trong tuyen giap 6,4% gii
n va 1,5% gii nam, t le nay con tang len gap 5-10 lan khi khao sat tuyen giap bang sieu am
hoac t thiet. Khao sat cac cuc c lay ra bang phau thuat cho thay, 42-77% la cuc tang san,
15-40% la u tuyen lanh tnh, 8-17% la ung th. ang chu y la phan ln cac benh ly tuyen giap
co ap ng tot vi ieu tr noi khoa hoac ngoai khoa; do o can co chien lc chan oan chnh
xac va hieu qua e ch nh ung cac trng hp can phau thuat, giam bt nhng cuoc mo
khong can thiet. Cac phng phap chan oan c thc hien truc tien bao gom nh lng
TSH, T3 va T4 trong mau, sieu am tuyen giap va chan oan te bao hoc choc hut bang kim nho
(FNA: fine needle aspiration cytology); phng phap FNA c anh gia cao do co tnh an
toan, de thc hien, re tien va o chnh xac cao (o nhay tren 95%, o ac hieu 99%).
Benh ly tuyen giap co the c phan thanh 4 nhom chnh: d tat bam sinh, viem, tang
san tuyen giap va u.
I. CAC D TAT BAM SINH (congenital anomalies):

1. Vo tao tuyen giap (athyrosis):
La mot d tat hiem gap vi xuat o khoang 1/ 4000 tre s sinh. Do mam tuyen giap
khong phat trien gay thieu hut hoan toan hormon, tre b benh tr on (cretinism) bao gom cac
trieu chng nh cham phat trien tam than van ong, da kho, 2 mat xa nhau, mui tet, li to. e
phong tranh benh nay, can phat hien sm ngay t thi ky s sinh e tien hanh ieu tr bang
hormon thay the (Hnh 2).
2. Mo giap lac cho (heterotopic thyroid tissue):
Do bat thng trong qua trnh chui xuong cua mam tuyen giap trong thi ky phoi thai:
khong chui xuong, chui xuong khong hoan toan hoac chui sau qua mc; ket qua tao ra mo
giap lac cho ay li, vung di ham, thanh quan, trung that (Hnh 3).
V tr thng gap nhat cua mo giap lac cho la ay li, co the gay ra trieu chng kho
nuot hoac kho th. ang chu y la 70% cac trng hp nay lai khong co tuyen giap bnh
thng, do vay viec cat bo mo giap lac cho se a en tnh trang nhc giap, oi hoi phai ieu
tr thay the bang hormon suot i.
Mo giap lac cho cung co the b them cac ton thng nh viem, tang san, u; tng t mo
tuyen giap v tr bnh thng.
Hnh 2: Tre b vo tao tuyen giap Hnh 3: Cac v tr tuyen giap lac cho
3. Boc ong giap - li (thyroglossal duct cyst):

La u gia, c hnh thanh do ong giap - li van ton tai, khong b thoai hoa va tan bien.
Cac te bao trong ong hoat ong che tiet tao thanh boc cha dch vang ac, ng knh khong
qua 2-3 cm. Boc co the xuat hien bat ky ni nao tren ng i cua ong giap li, nhng a
so c thay vung tren xng mong. Tren vi the, boc c lot bi bieu mo lat tang hoac bieu
mo tru gia tang co long chuyen, mo em ben di co cha cac nang giap. (Hnh 4)
Phan ln boc ong giap li c phat hien ngay t tuoi nho, mot t trng hp khac khi
tuoi a ln. ieu tr khoi han bang phau thuat.
Hnh 4: Boc ong giap - li cha dch vang ac (A); lot bi bieu mo tru gia tang, mo em co nang giap (B)
II. VIEM TUYEN GIAP (thyroiditis):
1. Viem giap cap tnh (acute thyroidits):

Thng do cac vi khuan sinh mu (Staphylococcus, Streptococcus, Pneumococcus); mot
so t trng hp do virut, ky sinh trung, nam, thng xay ra tren c a suy giam mien dch. Vi
khuan en tuyen giap theo ng mau, ng bach huyet hoac lan trc tiep t cac o nhiem
khuan cua c quan lan can nh vung khau hau, tuyen nc bot. Bieu hien lam sang gom co
sot va au vung trc co.
Hnh thai ton thng: Tuyen giap to khong oi xng, co nhieu o ap xe nho (Hnh 5).
Tren vi the, mo tuyen co phan ng tiet dch, phu ne va tham nhap nhieu bach cau a nhan.
ieu tr bang khang sinh va dan lu o ap xe neu co.
Hnh 5: O ap xe tren 1 thuy giap a xe oi (A); O mu gom bach cau a nhan thoai hoa va ai thc bao
2. Viem giap hat (granulomatous thyroiditis):

Con goi la viem giap de Quervain; thng xay ra phu n trung nien vi trieu chng sot
va au ot ngot mot ben co, co the lan len tai va vung di ham. Nguyen nhan cha biet ro
nhng co le do virut v benh thng xuat hien sau mot nhiem khuan ng ho hap tren.
Hnh thai ton thng: tuyen giap to gap oi bnh thng, khong oi xng; tren mat cat
thay co nhng cuc mat o chac, mau trang nhat, kch thuc t vai milimet en 2 cm, co the
trong giong ung th. Tren vi the, cac nang giap c bao quanh bi cac o viem hat gom te bao
.
dang bieu mo, ai bao,
limpho bao va cac am
mo si; khong co chat
hoai t ba au nh trong
viem lao. (Hnh 6).
ieu tr noi khoa bang
aspirin, thuoc khang viem
khong steroid cho en
khi het trieu chng. Benh
t gii han, hoi phuc
hoan toan sau 1-2 thang
Hnh 6: Viem giap hat: nang

giap (1; Te bao dang bieu
mo (2) va ai bao (3) .
3. Viem giap t mien (autoimmune thyroiditis):

Theo quan niem hien nay, 2 loai viem giap trc ay c mo ta rieng biet - viem giap
limpho bao va viem giap Hashimoto - thc ra ch la nhng giai oan benh khac nhau cua viem
giap t mien. ac trng cua viem giap t mien la s xuat hien cac t khang the khang
peroxidase (xuc tac phan ng hu c hoa muoi iod trong tuyen giap), t khang the khang
throglobulin va t khang the chong lai thu the TSH tren be mat te bao nang giap (theo kieu c
che thu the), lam cho cac te bao nang giap b pha huy dan ; ket qua benh nhan luc khi benh
thng bnh giap nhng cang ve sau cang nhc giap.
a/ Viem giap limpho bao (lymphocytic thyroiditis):
Xay ra chu yeu tre em,
dien tien benh thng nhe va ngan.
Hnh thai ton thng: tuyen
giap hi to, eu, mat o tang, mat
cat vang nhat. Benh nhan van bnh
giap hoac ch b nhc giap nhe.
Tren vi the, cac nang giap co cau
truc bnh thng, cac te bao nang
giap cha b bien oi thanh te bao
Hrthle (te bao Askanazy); mo em
gia cac nang giap tham nhap
limpho bao va co the thay co s
thanh lap cac trung tam mam. (Hnh
7)
Hnh 7: Mo em gia cac nang giap tham nhap limpho bao
b/ Viem giap Hashimoto (Hashimotos thyroiditis):

Benh c Hashimoto mo ta lan au vao nam 1912, xay ra chu yeu phu n tren 40
tuoi.
Hnh thai ton thng: tuyen giap to gap 2-3 lan bnh thng (40-80 gram), lan toa oi
xng hoac tao nhieu cuc. Mat cat vang nhat, mat o chac. Tren vi the, mo ke gia cac nang
giap tham nhap rat nhieu limpho bao, tng bao, mo bao va co s thanh lap cac trung tam
mam ln; rai rac co vai am mo si. Cac nang giap b teo nho, giam so lng, cha t chat
keo. Phan ln cac te bao nang giap b bien oi thanh te bao Hrthle, la nhng te bao co nhan
tang sac, bao tng ai toan dang hat. (Hnh 8)
Hnh 8: ai the viem giap Hashimoto; vi the co s thanh lap cac trung tam mam (1) va te bao Hrthle (2)
Khi benh uc phat hien, 20% benh nhan viem giap Hashimoto co trieu chng nhc
giap va t le nay tang dan theo thi gian, moi nam them khoang 4%. ang chu y la nhng
benh nhan nay, co s gia tang nguy c b carcinom tuyen giap dang nhu va limphom. V vay,
ngoai viec ieu tr bang hormon thay the, co ch nh phau thuat cat bo tuyen giap khi co trieu
chng chen ep hoac nghi ng co u.
4. Viem giap Riedel (Riedels thyroiditis):

c Riedel mo ta t nam 1896, la 1 benh hiem gap, chu yeu xay ra phu n trong o
tuoi 30-60. Tuyen giap to t nhng co the gay kho th do hien tng hoa si gay chen ep kh
quan. Nguyen nhan cha c biet ro.
Hnh thai ton thng: tuyen giap to, khong oi xng, mat o cng nh go, dnh mo xung
quanh do co nhng dai mo x day i t vo bao tuyen giap en cac cau truc xung quanh. Dien
cat giong nh seo si trang dai. Tren vi the, mo tuyen giap teo et, cac nang giap b pha huy
va c thay bang mo si x day; co s tham nhap nhieu limpho bao va tng bao, tap trung
nhieu thanh cac tnh mach c va. (Hnh 9)
ieu tr kho khan, mot so benh nhan co ap ng vi steroid nhng hau het eu phai
can en phau thuat e giai ep.
Hnh 9: ai the viem giap Riedel nh mo seo si (A); vi the gom nang giap teo et (1), mo si x (2) va
cac limpho bao (3) (B).
III. TANG SAN TUYEN GIAP (thyroid hyperplasia):

La tnh trang tang sinh so lng nang giap va te bao nang giap. Tang san tuyen giap co
the xay ra tren toan bo tuyen giap goi la tang san lan toa, hoac tao thanh cac cuc trong tuyen
giap goi la tang san cuc; bieu hien tng ng tren lam sang la phnh giap lan toa va phnh
giap cuc (diffuse goiter, nodular goiter). Trong tang san tuyen giap, chc nang tuyen giap co
the bnh thng, cng giap hoac nhc giap.
Da vao c che benh sinh, hnh thai ton thng va ac iem lam sang, phan biet 3 loai
tang san tuyen giap sau:
A. Phnh giap loan sinh hormon (dyshormogenetic goiter):
Xay ra do thieu hut bam sinh cac enzym can thiet cho qua trnh san xuat va che tiet
hormon tuyen giap; phan ln cac thieu hut nay c di truyen theo kieu gen lan - nhiem sac
the thng. Tuy theo mc o thieu hut hormon, trieu chng phnh giap co the xuat hien ngay
t khi mi sinh, nhng phan ln ch xuat hien khi tre a c 1-2 tuoi. Tre co cac trieu chng
nhc giap nh mau met, s lanh, toc o suy ngh va noi nang cham chap; co the tien trien
thanh benh tr on trong trng hp thieu hut tram trong hormon tuyen giap.
Hnh thai ton thng: Tuyen giap phnh to, co nhieu cuc. Cac cuc co mat o chac, mat
cat nau xam, co the co cac dai mo si bao quanh. Tren vi the, cac cuc tang san c tao bi
cac am ac te bao nang giap hoac bi cac nang giap nho cha rat t chat keo. Trong mot so
trng hp, mo tuyen giap nam gia cac cuc co cac te bao nang giap vi nhan to nho khong
eu, tang sac, co hnh anh phan bao; co the gay nham lan vi carcinom tuyen giap dang nang.
(Hnh 10)
Can phat hien va ieu tr sm bang hormon thay the e tranh cac bien chng cham phat
trien tam than - van ong do tnh trang nhc giap. Phau thuat c danh cho nhng trng
hp phnh giap qua ln, gay bien dang mat tham my hoac gay chen ep.
Hnh 10: ai the tuyen giap phnh to, nhieu cuc (A); nang giap nho (1) va te bao khong ien hnh (2) (B).
B. Benh Basedow (Basedows disease):

Con goi la phnh giap oc lan toa (diffuse toxic goiter), phnh giap loi mat (exophthalmic
goiter), benh Graves.
Benh xay ra gii n nhieu hn gii nam (t le n/ nam: 5/1), trong o tuoi t 30 en 40.
Bieu hien lam sang gom co tnh trang phnh giap lan toa 2 thuy; i kem vi cac trieu chng
cng giap nh sut can, s nong, run tay, tim ap nhanh, loi mat. Xet nghiem mau co T3 va T4
tang, TSH giam thap.
Benh Basedow cung thuoc ve nhom benh ly t mien tng t benh viem giap
Hashimoto. Trong huyet thanh cua benh nhan co cac t khang the co kha nang gan ket vi thu
the TSH tren be mat te bao nang giap, kch thch te bao nang giap tang sinh va tang san xuat
T3 va T4.
Hnh thai ton thng:
Tuyen giap to eu 2 thuy, can nang t 50-150g, mat cat co mau o giong mo c van.
Tren vi the, tuyen giap tang san rat manh, tao bi cac nang giap co kch thc khong eu.
Nang giap c lot bi cac te bao hnh tru, nhan tron, tang sac va nam lech ve cc ay; long
nang cha rat t hoac khong co chat keo giap. nhng nang ln hn, te bao nang giap co
the tang sinh tao nhu tho vao trong long nang, co the gay nham lan vi carcinom tuyen giap
dang nhu. Trong mo em gia cac nang giap, co s tang sinh mach mau, tham nhap limpho
bao va co the co cac trung tam mam. Tnh trang loi mat trong benh Basedow la do hien tng
phu ne, tham nhap limpho bao, lang ong chat mucopolysaccharid va hoa si trong cac c
ngoai nhan cau va trong mo em cua hoc mat.(Hnh 11)
Hnh 11: Phnh giap loi mat (A); Tuyen giap to eu 2 thuy (B); mat cat mau o (C); tren vi the, te bao nang
giap tang sinh tao nhu (D), nang giap cha t chat keo giap (E)
Benh Basedow co the c ieu tr bang nhieu phng phap khac nhau nh dung thuoc
khang giap (propylthiouracil, methimazole), phau thuat cat giap gan tron, uong iod phong xa;
tuy nhien, tat ca cac phng phap nay eu khong co tac dung oi vi trieu chng loi mat.
C. Tang san cuc (nodular hyperplasia):
La loai benh ly tuyen giap thng gap nhat; co the phat hien tren lam sang 3-5% ngi
ln, 50% cac trng hp t thiet. Tang san cuc thng xay ra ngi tre (t sau tuoi day th
en tuoi trng thanh), gii n nhieu hn gii nam. Tuy theo nguyen nhan va c che benh
sinh, phan biet 2 loai tang san cuc:
- Phnh giap dch vung (endemic goiter): la tnh trang phnh giap xay ra mot so a
phng vi xuat o hn 10% dan so; thng thuoc ve cac vung nui hoac vung nam sau trong
at lien, co ham lung iod trong at va nc rat thap. Nguyen nhan gay phnh giap tai nhng
vung nay la do s thieu hut iod trong thc pham, tuyen giap khong san xuat u T3 va T4 lam
tuyen yen tang tiet TSH, kch thch tuyen giap tang san tao cuc.
- Phnh giap le te (nonendemic/ sporadic goiter): la nhng trng hp phnh giap xay ra
ngoai nhng vung a d noi tren. Nguyen nhan va c che benh sinh cua loai phnh giap nay
van cha c ro; tuyen giap khong san xuat u hormon co the la do tac ong phoi hp cua
nhieu yeu to khac nhau nh:
* S dung cac loai thc pham co cha cac chat khang giap nh thioglucoside (cai bap,
cu cai), cyanoglucoside (bot san, bap, khoai lang, mang tre), flavinoid (hat ke).
* Tang nhu cau hormon tuyen giap trong giai oan day th hoac mang thai.
* Tang tnh ap ng oi vi TSH cua mot so nhom te bao nang giap.
Tuy vay, hau het cac benh nhan cua ca 2 loai tang san cuc noi tren khi c phat hien
tren lam sang eu co chc nang tuyen giap bnh thng (bnh giap), TSH khong cao.
Hnh 12: Tang san cuc tuyen giap: tuyen giap phnh to, co nhieu cuc (A,B); cuc co the co vo bao khong
hoan toan (mui ten), mat cat mau nau, co nhng vung xuat huyet(*) (C).
Hnh thai ton thng: giong nhau cho ca 2 loai tang san cuc. Tuyen giap phnh to, khi
au co dang lan toa nhng ch sau mot thi gian ngan se xuat hien cac cuc co ng knh t
mot en vai cm; so lng cuc tang dan theo thi gian dien tien benh, co the chiem toan bo
tuyen giap. Tuyen giap co the rat ln, can nang en 2 kg; gay bien dang co va chen ep kh
quan. Tren mat cat, cac cuc co mau nau, mat o thay oi, c bao quanh bi cac dai si
hoac mot vo bao si khong hoan toan. Gia cac cuc la mo giap bnh thng, khong b chen
ep. Trong cac cuc ln, co the thay hien tng xuat huyet, thoai hoa boc, hoa calci. Boc co the
at en kch thc ln, ng knh 4-5cm, trong cha chat keo mau vang trong hoac mau nau
o khi co xuat huyet kem theo (Hnh 12). Tren vi the, cac cuc c tao bi cac nang giap co
kch thc va cau truc rat a dang: ben canh nhng nang giap nho lot bi cac te bao hnh tru
tang sinh tao nhu, co nhng nang giap gian rong cha ay chat keo vi te bao nang giap b ep
det. Cac nang giap co the b v, xuat huyet va e thoat chat keo ra ngoai mo em; gay phan
ng viem gom co cac limpho bao, ai thc bao ong hemosiderin va ai bao nhieu nhan.
(Hnh 13)
Hnh 13: Cac cuc tang san (1) c bao quanh bang dai si (2),mo giap gia cac cuc (3) khong b chen ep
(A). Cac nang giap tang san to nho khong eu, co cho tao nhu (mui ten, B).
oi vi cac trng hp tang san cuc mc o t nhe en va, ieu tr bang thyroxin co
the lam giam kch thc cua phnh giap. Phau thuat c ch nh oi vi cac trng hp phnh
giap qua ln, gay chen ep hoac nghi ng co u.
Bang sau ay tom tat lai cac ac iem chnh giup phan biet 3 loai tang san tuyen giap:
Tang san tuyen giap C che benh sinh Hnh thai Chc nang
ton thng T. giap
Phnh giap loan sinh Thieu hut bam sinh cac Tang san cuc Nhc giap
hormon enzym tong hp hormon
Benh Basedow T mien Tang san lan toa Cng giap
(Phnh giap oc lan toa)
Tang san cuc
- Phnh giap dch vung Thieu iod Tang san cuc,
- Phnh giap le te Cha ro (sau 1 tang san lan Bnh giap
toa tam thi)
IV. U TUYEN GIAP

A. U lanh
Chu yeu la u tuyen tuyen giap dang nang; mot vai trng hp la u m, u mach mau
U tuyen tuyen giap dang nang (follicular adenoma):
La u lanh, xuat nguon t te bao nang giap; xay ra chu yeu gii n. Bieu hien lam sang
la 1 cuc n oc trong 1 thuy giap, khong au; chc nang tuyen giap van bnh thng (bnh
giap).
Hnh thai ton thng: u hnh tron hoac bau duc, ng knh t 1-3 cm. U gii han ro,
c bao boc hoan toan bi 1 vo bao si mong; mo giap bnh thng quanh u b chen ep. Mat
cat u ong nhat, mau vang nhat hoac o nau, co the co nhng o xuat huyet va thoai hoa boc.
Hnh 14: U tuyen co vo bao hoan toan, mat cat ong nhat (A); vi the cho thay mo giap chung quanh u b
chen ep (B)
Tren vi the, u c tao bi cac nang tuyen tng oi ong eu, n dang. Te bao u co
cau tao giong te bao nang giap bnh thng; tuy theo cach sap xep cua te bao u, co the phan
biet 4 dang vi the khac nhau cua u tuyen nh sau:
- U tuyen phoi (embryonal adenoma): te bao u ket thanh cac am hoac be ac, khong
hnh thanh nang tuyen.
- U tuyen nang nho (microfollicular adenoma): con goi u tuyen thai (fetal adenoma), te
bao u tao thanh cac nang tuyen nho hn nang giap bnh thng quanh u, cha t chat
keo.
- U tuyen nang thng (normofollicular adenoma): nang tuyen cua u bang vi nang giap
bnh thng.
- U tuyen nang ln (macrofollicular adenoma): nang tuyen cua u ln hn nang giap bnh
thng.
Thc ra, viec phan biet tren khong quan trong v khong co y ngha ve mat lam sang. Trai
lai, phai phan biet c gia u tuyen vi 1 cuc tang san noi troi trong benh tang san cuc, gia
u tuyen va carcinom tuyen giap dang nang, da vao cac ac iem c tom tat trong bang
sau:
Tang san cuc U tuyen Carci. dang nang

So lng Nhieu cuc 1 cuc 1 cuc
Vo bao si Khong co hoac co Co Co
khong hoan toan
Cau truc nang tuyen a dang ong eu, n dang Giong u tuyen
Mo giap xung quanh Bnh thng B chen ep B te bao u xam nhap
Xam nhap vo bao Khong Khong Co
va Mach mau
U tuyen tuyen giap dang nang co mot so bien the trong o te bao u rat khac thng, co
the gay nham lan vi mot ung th:
- U tuyen khong ien hnh (atypical adenoma): u co mat o te bao cao; te bao u ket
thanh am ac hoac nang tuyen ac; co cho, te bao u tang sinh thanh cac am te bao
hnh thoi.
- U tuyen co nhan quai (adenoma with bizarre nuclei): te bao u co nhan rat ln, tang sac,
d dang.
- U tuyen te bao Hrthle (Hrthle cell adenoma): u co mat o te bao cao; te bao u co
nhan ln, hach nhan ro, bao tng ai toan dang hat. Cac te bao u ket thanh am ac
hoac nang tuyen ac, rat t chat keo. (Hnh 15)
Hnh 15: U tuyen co nhan quai (A); U tuyen te bao Hrthle (B)
Phng phap ieu tr tieu chuan oi vi u tuyen tuyen giap dang nang la phau thuat cat
tron thuy giap.
B. U ac
Chiem khoang 1,5% tong so cac loai ung th; xay ra gii n nhieu hn gii nam. So
lieu ghi nhan ung th (2004-08) tai TP. Ho Ch Minh va Ha noi va cho thay ung th tuyen giap
ng hang th 5 va 6 trong 10 loai ung th thng gap gii n.
Ung th tuyen giap chu yeu la u nguyen phat; u th phat chiem khong qua 1%,
thng do di can t ung th da, vu, than va phoi.
Trong u nguyen phat cua tuyen giap, hn 99% la carcinom, xuat nguon t te bao nang
giap hoac te bao C. Cac loai khac, nh limphom va sarcom, chiem khong qua 1%.
Bang sau ay cho thay t le tng oi cua tng loai u nguyen phat:
Carcinom xuat nguon t te bao nang giap (HMMD: thyroglobulin (+), T3 (+), T4 (+))
Carcinom dang nhu 60-80%
Carcinom dang nang 15-20%
Carcinom te bao Hrthle 2-3%
Carcinom kem biet hoa 4%
Carcinom khong biet hoa 1-10%
Carcinom xuat nguon t te bao C (HMMD: thyroglobulin (), T3 (), T4 (), calcitonin(+))
Carcinom dang tuy 5-10%
Limphom, sarcom 1%
Bieu hien lam sang noi chung cua ung th tuyen giap la s xuat hien cua mot khoi u
vung trc co; kch thc thay oi, t rat nho kho s thay cho en rat ln, xam lan mo xung
quanh, chen ep kh quan. Benh nhan co the co trieu chng di can hach vung hoac di can xa
theo ng mau en phoi, xng, da ieu ang mng la 90-95% ung th tuyen giap thuoc
loai biet hoa tot, t gay t vong cho benh nhan neu c phat hien sm va cha tr kp thi.
1. Carcinom dang nhu (papillary carcinoma):

La loai carcinom thng gap nhat cua tuyen giap, chiem t le 60-80% ung th tuyen giap;
tuoi mac benh trung bnh la 40 tuoi, tuy nhien u co the xay ra moi la tuoi, ke ca tre em. Gii
n mac benh nhieu hn gii nam gap 2-3 lan.
Tia phong xa, che o an qua d iod, viem giap Hashimoto a c chng minh la cac
yeu to lam tang nguy c mac benh.
Hnh thai ton thng: khoi u co kch thc thay oi, t rat nho (ng knh < 1 cm) cho
en rat ln (ng knh 7-8 cm), trung bnh vao khoang 2-3cm. U ac, mat o chac, mat cat
trang xam, co the co nhng vung hoa calci va thoai hoa boc. U khong co vo bao, xam nhap
vao mo giap xung quanh. Tren vi the, u cau tao bi cac cau truc nhu phan nhanh, co truc lien
ket mach mau, c phu bi 1 lp te bao bieu mo hnh vuong. Te bao u co 3 ac trng sau:
- Nhan tron hoac bau duc, rong, sang, khong co hach nhan, xep chong chat len nhau.
- Nhan co kha doc (do mang nhan gap lai).
- Nhan co the vui ai toan ( do bao tng an lom vao nhan).
Trong truc lien ket mach mau cua cac nhu, co the thay the cat (the psammoma), la mot
cau truc calci gom nhieu lp ong tam, tao bi s lang ong calci theo kieu calci hoa nghch
dng. Mo em u co tham nhap limpho bao va hoa si. (Hnh 16)
Ben canh cau truc nhu, te bao u co the xep thanh nang tuyen, oi khi nhieu en mc tao
thanh 1 bien the goi la carcinom dang nhu bien the nang (follicular variant). Ngoai ra, con co
the gap cac bien the khac nh bien the te bao tru, bien the x hoa lan toa Cac bien the nay
c ghi nhan co o ac tnh cao hn so vi dang carcinom dang nhu ien hnh.
Carcinom dang nhu tien trien cham, co the pha v vo bao tuyen giap va an lan ra cac
mo ngoai tuyen giap. Carcinom dang nhu thng sm cho di can theo ng bach huyet en
hach; vao thi iem c chan oan, 50% benh nhan a co di can hach co va 20% th co di
can hach co nh la trieu chng au tien cua benh. Di can theo ng mau hiem gap, chiem t
le 5%, chu yeu en en phoi.
ieu tr thay oi tuy kch thc u, co the ch cat 1 thuy giap hoac cat tron tuyen giap; co
hoac khong i kem vi ieu tr bang iod phong xa I131. Carcinom dang nhu noi chung thuoc loai
biet hoa tot; neu benh nhan la gii n, tre hn 20 tuoi, u < 4cm, hnh anh vi the la dang nhu
ien hnh th co tien lng rat tot, t le t vong sau 20 nam ch co 6%.
Hnh 16: Carcinom dang nhu co the nho hn 1 cm (mui ten, A) hoac ln va khong vo bao (B,C).
Tren vi the, co cac cau truc nhu phan nhanh (D), the psammoma (mui ten, E). Te bao u
co nhan sang, chong chat len nhau, co kha doc (mui ten, F), the vui trong nhan (mui ten, G).
2. Carcinom dang nang (follicular carcinoma):

Chiem t le 15-20% ung th tuyen giap. Tuoi mac benh trung bnh la 50 tuoi, gii n mac
benh nhieu hn gii nam.
Cac yeu to lam tang nguy c mac benh gom co tia phong xa va che o an thieu iod.
Hnh thai ton thng: u co ng knh trung bnh t 2-3 cm, mat o chac, vo bao ro, mat
cat nau nhat, co nhng o xuat huyet nho. Te bao u co cau tao giong te bao nang giap bnh
thng; xep thanh be, am ac, cac nang tuyen nho, va hoac ln. Nh vay, hnh anh ai the
va vi the cua carcinom dang nang co the giong het u tuyen tuyen giap dang nang lanh tnh;
tnh chat ac tnh cua khoi u ch co the xac nh qua hien tng xam nhap cua te bao u vao
trong vo bao hoac cac mach mau. Tuy theo mc o xam nhap, phan biet 2 dang carcinom
dang nang vi y ngha tien lng khac han nhau:
- Carcinom dang nang xam nhap toi thieu (minimally invasive follicular carcinoma): te
bao u xam nhap qua toan bo be day vo bao, xam nhap vao cac mach mau trong hoac ngoai
vo bao nhng so lng khong qua 3 mach mau.
- Carcinom dang nang xam nhap lan rong (widely invasive follicular carcinoma): te bao u
xam nhap qua vo bao vao mo giap xung quanh, xam nhap vao 4 mach mau. (Hnh 17)
Hnh 17: Carcinom dang nang, co vo bao ro, mat cat nau nhat, co vai o xuat huyet (A). Tren vi the, te bao
u tao thanh nang tuyen nho (B), giong nh u tuyen lanh; ch khac hien tng xam nhap vo bao
(mui ten, C) va xam nhap mach mau (D)
Trai vi carcinom dang nhu, carcinom dang nang thng cho di can theo ng mau,
chu yeu en phoi va xng, t khi cho di can hach. T le di can cua carcinom dang nang xam
nhap toi thieu la 1-5%, cua carcinom dang nang xam nhap lan rong la 75%; do vay, loai ung
th au c xep vao o biet hoa tot, co t le song them 10 nam at gan 100%, loai sau vao
o biet hoa kem, t le song them 10 nam ch at t 25-45%.
ieu tr thay oi tuy mc o xam nhap, co the ch cat 1 thuy giap hoac cat tron tuyen
giap; co hoac khong kem theo ieu tr bang iod phong xa I131.
3. Carcinom te bao Hrthle (Hrthle carcinoma):

U xay ra ngi ln tuoi, gii n nhieu hn gii nam. U co ng knh trung bnh 5 cm,
co vo bao, cau tao bi cac te bao co nhan ln, hach nhan ro, bao tng ai toan dang hat.
Tng t carcinom dang nang, hnh anh ai the va vi the cua carcinom te bao Hrthle co the
giong het u tuyen te bao Hrthle lanh tnh; tnh chat ac tnh cua khoi u ch co the xac nh qua
hien tng xam nhap cua te bao u vao trong vo bao hoac cac mach mau; va cung phan biet 2
mc o xam nhap, xam nhap toi thieu va xam nhap lan rong. (Hnh 18)
Hnh 18: U chiem het 1 thuy tuyen giap co vo bao, mat cat vang, co cho hoai t, (A); te bao u cung giong
te bao u tuyen te bao Hrthle lanh tnh (B), ch khac hien tng xam nhap mach mau va vo bao (C)
Carcinom te bao Hrthle c xep vao o biet hoa kem, thng cho di can theo
ng mau en phoi va xng, t cho di can hach. ieu tr bang phau thuat cat tron hoac gan
tron tuyen giap, co hoac khong ket hp them vi ieu tr bang iod phong xa I131. T le song
them 5 nam ch at 50%.
4. Carcinom kem biet hoa (poorly differentiated carcinoma):

Chiem t le 4% ung th tuyen giap, tuoi mac benh trung bnh la 55 tuoi, gii n mac
benh nhieu hn gii nam. U ac, mat o chac, thng khong co vo bao; mat cat u trang xam,
co cac o hoai t. Cac te bao u co kch thc nho, t le nhan/ bao tng cao; t le phan bao
tang. Te bao u xep thanh cac ao te bao ac hnh tron hoac bau duc, cha t chat keo. U
thng cho di can hach va di can xa theo ng mau en gan va xng; vao thi iem u c
phat hien, 36% so benh nhan a co di can hach va 26% co di can xa. ay la loai ung th co
tien lng xau, t le t vong cao (Hnh 19).
Hnh 19: Carcinom kem biet hoa: mat cat trang xam, co o hoai t (A). Te bao
u hp thanh am ac hnh tron (B).
5. Carcinom khong biet hoa (undifferentiated carcinoma):

Chiem t le 1-10% ung th tuyen giap. Benh nhan thng ln tuoi, trung bnh la 65 tuoi,
gii n mac benh nhieu hn gii nam. U phat trien nhanh, chiem toan bo tuyen giap, xam nhap
ra ngoai gay kho th va kho nuot; cho di can theo ng bach huyet va ng mau. U ac,
cng chac, khong vo bao, mat cat trang xam, co nhieu o hoai t va xuat huyet. Cac te bao u
co the co hnh a dien nh te bao gai, hnh thoi nh te bao si, hoac giong ai bao nhieu nhan;
nhan d dang, t le phan bao rat cao. (Hnh 20)
Hnh 20: Carcinom khong biet hoa: u rat ln, mat cat nhieu o hoai t xuat huyet (A), tren vi the, gom cac
te bao u d dang, phan bao bat thng (mui ten, B)
Carcinom khong biet hoa la loai ung th co o ac tnh cao, tien lng cc ky xau,
ieu tr khong hieu qua va hau het benh nhan eu t vong trong vong 6 thang ke t khi benh
c phat hien.
6. Carcinom dang tuy (medullary carcinoma):
Chiem t le 5-10% ung th tuyen giap. U xuat nguon t te bao C, gom 2 the:
- The le te (spradic form): chiem 80% trng hp, benh nhan co tuoi trung bnh la 50
tuoi.
- The gia nh (familial form): benh nhan tre hn, tuoi trung bnh la 35 tuoi. Trong the
nay, carcinom dang tuy tuyen giap ch la 1 bieu hien cua hoi chng tan sinh a tuyen noi tiet
typ 2 (multiple endocrine neoplasia, MEN type 2). Hoi chng nay la 1 benh di truyen theo kieu
gen troi nhiem sac the thng (ot bien tien-oncogen ret nam tren nhiem sac the 10), ac
trng bi s xuat hien ong thi u nhieu tuyen noi tiet khac nhau nh tuyen giap, tuyen can
giap, tuyen thng than Mot khi phat hien ra the ung th tuyen giap nay, can phai tam soat u
cac thanh vien khac trong cung gia nh cua benh nhan bang cach nh lng calcitonin
trong mau.
Hnh 21: Carcinom dang tuy: u chiem tron thuy trai tuyen giap trong the le te (A); the gia nh co nhieu cuc
(mui ten, B); te bao u a dang, mo em co chat amyloid (mui ten, C); sau khi nhuom o vi pham
nhuom o congo, oi sang mau vang xanh di anh sang phan cc (mui ten, D); nhuom hoa mo
mien dch, te bao cho phan ng dng tnh (bat mau nau) vi calcitonin (E).
Hnh thai ton thng: U dang cuc, ac, gii han ro nhng khong co vo bao, kch thc
thay oi t di 1cm en vai cm, mat cat trang xam. The le te thng ch co 1 cuc, the gia nh
co nhieu cuc ca 2 thuy giap. Tren vi the, te bao u co hnh thai a dang, hnh tron hoac bau
duc giong tng bao hoac te bao Hrthle, hnh a dien giong te bao gai, hnh thoi; nhan te bao
hnh tron hoac bau duc, chat nhiem sac dang hat mn. Cac te bao u xep thanh am ac hoac
be, xam nhap vao mo giap xung quanh. Trong mo em gia cac te bao u co s lang ong chat
amyloid, co ban chat la calcitonin do te bao u san xuat. (Hnh 21)
Carcinom tuyen giap dang tuy cho di can en hach co va hach trung that, di can theo
ng mau en phoi, xng va gan. ieu tr chu yeu bang phau thuat cat tron tuyen giap va
nao hach co. T le song them 10 nam at t 40-50%.

1. Boc ong giap li thng thay tren ng gia co, tai v tr:
A/ Goc li B/ Tren xng mong C/ Trc kh quan
D/ Hom c D/ Trung that tren
2. Mot benh nhan n co trieu chng mau met, s lanh, tuyen gap phnh to nhieu cuc; xet
nghiem mau co T3 va T4 giam, TSH tang, t khang the khang peroxidase tang; choc hut te bao
thay te bao Hurtle va limpho bao. Co the ngh en benh:
A/ Basedow B/ Viem giap limpho bao C/ Viem giap Hashimoto
D/ Viem giap ban cap E/ Viem giap Riedel
3. Trong benh tang san cuc:

A/ Tuyen giap co nhieu cuc B/ Cuc chen ep mo giap xung quanh
C/ Cuc co the b thoai hoa boc
4. Ve carcinom tuyen giap dang nhu, phat bieu sau KHONG UNG:
A/ La loai ung th tuyen giap thng gap nhat
B/ Gii n mac benh nhieu hn gii nam
C/ Co the xay ra tre em
D/ Thung sm cho di can theo ng mau
E/ Co the chan oan chnh xac trc mo bang ky thuat choc hut kim nho
5. The psammoma c thay nhieu nhat trong loai carcinom nao cua tuyen giap:
A/ Carcinom dang tuy B/ Carcinom dang nhu C/ Carcinom dang nang
D/ Carcinom kem biet hoa E/ Carcinom khong biet hoa
6. Tnh chat ac tnh cua carcinom tuyen giap dang nang c bieu hien :
A/ Hnh thai te bao u B/ Phan bao bat thng C/ Khong co vo bao
D/ S xam nhap te bao u vao vo bao va mach mau E/ Di can hach co
7. Loai carcinom tuyen giap xuat nguon t te bao C:

A/ Carcinom dang tuy B/ Carcinom dang nhu C/ Carcinom dang nang
D/ Carcinom kem biet hoa E/ Carcinom khong biet hoa
8. Mot benh nhan n 60 tuoi nhap vien v noi 1 khoi u vung tran, choc hut kim nho cho thay u
c tao bi cac te bao nang giap gan nh bnh thng; 6 thang trc o, benh nhan a c
cat bo tuyen giap tai 1 benh vien khac vi chan oan u tuyen tuyen giap dang nang. Loai benh
ly tuyen giap ma benh nhan a thc s mac phai nhieu kha nang nhat la:
A/ U tuyen dang nang B/ Carcinom dang nang C/ Carcinom dang tuy
D/ Carcinom khong biet hoa E/ Carcinom dang nhu bien the nang
Benh Ly He Sinh Duc Nam 271
BENH LY HE SINH DUC NAM
Muc tieu :
1. Ke ten cac ton thng tinh hoan va mao tinh hoan.
2. Mo ta va phan tch cac loai u tinh hoan.
3. Lien he lam sang u te bao mam
4. Ke ten cac ton thng dng vat.
5. Mo ta va phan tch cac loai carcinom dng vat.
6. Ke ten cac ton thng tuyen tien liet.
7. Mo ta va phan tch tang sinh lanh tnh tuyen tien liet.
8. Mo ta va phan tch carcinom tuyen tien liet.
BENH LY TINH HOAN VA MAO TINH HOAN:

ac iem benh ly cua tinh hoan va mao tinh hoan tng oi khac biet nhau: benh ly chu
yeu cua mao tinh hoan la cac viem nhiem con cua tinh hoan la cac u bu. S lien quan mat
thiet ve mat giai phau khien cho benh ly mao tinh hoan co the lan de dang sang tinh hoan va
ngc lai. (Hnh 1)
Hnh 1: S o cau tao giai phau hoc he sinh duc nam, tinh hoan va mao tinh hoan
A. TINH HOAN AN (cryptorchidism):

Trong thi ky phoi thai, tinh hoan phat trien t mao sinh duc nam pha tren cua thanh
bung sau, cac te bao mam (germ cell) se di chuyen t tui noan hoang vao mao sinh duc. Khi
thai c 7 thang tuoi, tinh hoan bat au i xuong doc theo thanh bung sau, chui qua ong ben
e xuong bu; mot lp mang bung cung c keo theo, tao thanh 1 tui mang bao lay tinh hoan.
khoang 5% tre trai, qua trnh di chuyen cua tinh hoan b ngng na chng; tinh hoan b ket lai
trong o bung hoac trong ong ben, goi la tinh hoan an.
Nhiet o cao trong o bung se c che qua trnh phat trien bnh thng cua cac te bao sinh
duc; do o tinh hoan an thng co kch thc nho, cau tao bi cac ong sinh tinh ch cha toan
te bao Sertoli va co mang ay rat day. Tinh hoan an thng ch co 1 ben (75% trng hp), 2
ben (25%). Nguy c ang s nhat cua tinh hoan an la kha nang hoa ac neu no khong c keo
xuong hoac cat bo. (Hnh 2)
Hnh 2: V tr tinh hoan an (A); tren vi the,ong sinh tinh ay te bao Setoli, mang ay rat day (B)
B. VIEM TINH HOAN (orchitis):

Tac nhan gay viem tinh hoan thng phai i qua mao tinh hoan, do o viem tinh hoan
thng ket hp vi viem mao tinh, goi la viem tinh hoan - mao tinh (epididymo - orchitis). ang
chu y la cac loai viem tinh hoan - mao tinh di ay:
1. Viem cap tnh tinh hoan - mao tinh: thng do lau cau trung va Chlamydia trachomatis (lay
truyen qua ng sinh duc), hoac do E.coli va cac vi khuan Gram am khac.
ai the: tinh hoan b sng to va rat au
Vi the: co hien tng tham nhap te bao viem cap tnh vao mo ke va cac ong sinh tinh,
phu viem, xuat huyet tng am; trng hp viem nang, co the gay hoai t hoa long, tao ra cac
o ap xe trong mao tinh hoan va tinh hoan. S hoa si trong giai oan sa cha tiep theo co the
gay ra vo sinh ve sau. (Hnh 3A)
2. Viem lao mao tinh hoan: thng do vi khuan lao t 1 sang thng lao phoi mn ng
mau en, hoac t 1 sang thng lao cua than va ng tieu di xam nhap vao theo ng ong
dan tinh. Khoang 3% trng hp, ton thng xay 2 ben. Mao tinh hoan b pha huy bi cac
nang lao cha ay chat ba au (ton thng co the lan sang ca tinh hoan). Viem lao mao tinh
hoan co the lan sang tinh hoan. (Hnh 3B)
Hnh 3: Viem tinh hoan va mao tinh hoan do lau cau trung, tao o ap xe trong mao tinh hoan (A); Viem lao
vi cac u hat lao trong tinh hoan va mao tinh hoan (B)
3. Viem tinh hoan do quai b: benh quai b la mot benh nhiem virut toan than, thng xay ra
tre em. Khoang 25% trng hp quai b co bien chng viem tinh hoan, xuat hien sau sng tuyen
mang tai khoang 1 tuan. Thng ch co 1 tinh hoan b viem (70% trng hp), neu ca 2 tinh
hoan eu b th co the gay ra vo sinh sau nay.
ai the: tinh hoan sng to va au do phu ne mo ke.
Vi the: co hien tng phu viem va tham nhap cac te bao n nhan gom ai thc bao,
limpho bao va tng bao. S gia tang ap lc trong tinh hoan do phu ne co the chen ep cac
mach mau, gay thieu mau cuc bo va hoai t cac ong sinh tinh.
4. U hat tinh trung (sperm granuloma): co dang cac cuc cng va au, nam doc theo ong dan
tinh (thng ngay cho that ong dan tinh) hoac mao tinh. Tren vi the, co hnh anh cac u hat
gom cac te bao dang bieu mo, ai bao nhieu nhan, limpho bao va tng bao (co le e chong lai
cac tinh trung lot ra ngoai ong dan tinh).
C. TRAN DCH TINH MAC (hydrocele):
La tnh trang dch trong bao tinh hoan, ay la nguyen nhan gay sng bu thng gap
nhat. Phan biet 2 loai:
- Tran dch tinh mac bam sinh: xuat hien ngay t nhng tuan le au tien sau sinh, do bao
tinh hoan con thong vi o bung.
- Tran dch tinh mac th phat: do bao tinh hoan b viem gay ong dch xuat thanh huyet,
t huyet hoac xuat huyet; thng xay ra sau cac ton thng viem hoac u cua tinh hoan va mao
tinh. Tnh trang dch nay co the lam day va x hoa bao tinh hoan. (Hnh 4A)
D/ TRAN MAU TINH MAC (hematocele):
La tinh trang xuat huyet vao trong bao tinh hoan, thng do chan thng bu hoac do u
tinh hoan. (Hnh 4B)
Hnh 4: Tran dch tinh mac, lam cang bao phong bao tinh hoan (mui ten A);
Tran mau tinh mac, ep dep tinh hoan (*) (B)
E. U TINH HOAN (testicular tumors):

Hau het la u ac tnh. Ung th tinh hoan tng oi t gap; ghi nhan ung th tai benh vien
Ung bu Tp.HCM 2008 cho thay ung th tinh hoan ch chiem 0,5% ung th gii nam; nhng
ay lai la loai ung th hay xay ra ngi tre, vi xuat o cao nhat trong o tuoi 15-34.
1. Phan loai
Theo To chc Y te The gii, u tinh hoan c chia thanh 2 loai chnh:
U te bao mam (chiem 95% u tinh hoan)
* n thuan 1 kieu mo hoc (chiem 40% u te bao mam):
- U tinh bao
- Carcinom phoi
- U tui noan hoang
- Carcinom em nuoi
- U quai
* Hon hp nhieu kieu mo hoc (chiem t le 60% u te bao mam): thng la gia u quai,
carcinom phoi, u tui noan hoang va carcinom em nuoi.
U mo em - day sinh duc (chiem 5% u tinh hoan)

- U te bao Leydig
- U te bao Sertoli
2. Nguyen nhan
Tinh hoan an la nguyen nhan gay u tinh hoan c biet ro nhat; 10% u tinh hoan xay ra
tren tinh hoan an; cha ro c che cua s lien he nay. Chan thng khong phai la mot nguyen
nhan gay u tinh hoan.

a/ CAC U TE BAO MAM (germ cell tumors):
a.1/ U TINH BAO (seminoma):
La loai u te bao mam thng gap nhat (chiem 30% u te bao mam), hau nh khong bao
gi xay ra tre em, thng gap nhat trong o tuoi 30-50. U nay rat giong vi u nghch mam cua
buong trng.
ai the: u xam chiem toan bo tinh hoan, lam tinh
hoan sng to (kch thuc co the to gap 10 lan bnh
thng), mat cat mau nau nhat, kha ong nhat. U t khi
xam nhap vao bao tinh hoan, nhng oi khi lan tran vao
mao tinh hoan, thng tinh va bu.(Hnh 5)
Vi the: phan biet 3 loai u tinh bao.
- U tinh bao ien hnh: chiem 85% u tinh bao. U
cau tao bi 1 loai te bao xep thanh tng dai hoac am,
phan cach vi nhau bang cac dai si collagen mong co
tham nhap nhieu limpho bao. Te bao u hnh tron hoac a
giac; mang te bao ro, bao tng sang; nhan nam chnh
gia, am mau, cha 1-2 hach nhan. Thng t co phan
bao. (Hnh 6A,B)
- U tinh bao sinh tinh: cau tao bi 3 loai te bao
tron lan vao nhau (Hnh 6C)
* Te bao kch thc trung bnh (15-18 m), nhan Hnh 5: U tinh bao xam chiem toan bo
tron, bao tng ai toan. ay la loai te bao chiem a so. tinh hoan
* Te bao nho (6-8m) co hnh anh tng t tinh bao, nhan tron, bao tng t.
* Te bao khong lo (50-100m), co 1 hay nhieu nhan, nam rai rac trong u.
- U tinh bao loan san: cau tao bi cac te bao a dang va d dang, thng thay co cac te
bao khong lo va co nhieu phan bao (> 3 phan bao/ 1 vi trng ln VKx40). (Hnh 6D)
Hnh 6: U tinh bao ien hnh, cac am te bao u ngan cach bi dai si (mui ten) tham nhap limpho bao (A,B).
U tinh bao sinh tinh vi 3 loai te bao (C). U tinh bao loan san nhieu phan bao (mui ten,D)
a.2/ CARCINOM PHOI (embryonal carcinoma):

Carcinom phoi dang n thuan chiem 3% u te bao mam, thng gap trong khoang tuoi 20
- 30 tuoi.
ai the: U co the rat nho, khoang 2-3 cm ng knh nhng cung co the rat ln, xam
nhap vao bao tinh hoan va mao tinh hoan. Mat cat a dang khong ong nhat, vi nhng vung
hoai t va xuat huyet.
Vi the: cau tao bi cac te bao ln d dang, nhan ln am mau, hach nhan ln. Cac te bao
xep thanh cac cac am ac hoac cac ong tuyen. (Hnh 7)
Hnh 7: U carcinom phoi co mat khong ong nhat (A) ; te bao u xep thanh cau truc tuyen (B).
a.3/ U TUI NOAN HOANG (yolk sac tumor):

La loai u tinh hoan thng gap tre em < 3 tuoi. U cung co the xay ra ngi ln nhng
thng di dang hon hp vi cac loai u te bao mam khac.
ai the: u mem, mat cat khong ong nhat, mau xam nhat, co nhng vung xuat huyet va
thoai hoa boc.
Vi the: u cau tao bi cac te bao hnh vuong hoac det, ket hp thanh 1 mang li cac cau
truc dang ong, hoac phu len cac nhu lien ket co mach mau gia; cac nhu nay tho vao trong
long cac ong lot bi te bao u, tao thanh 1 cau truc rat ac trng cua u tui noan hoang goi la the
Schiller - Duval. Mot iem ac trng khac cua u tui noan hoang la cac te bao u co kha nang san
xuat ra alphafetoprotein (AFP). (Hnh 8)
Hnh 8: U tui noan hoang co mat cat khong ong nhat, co xuat huyet va thoai hoa boc (A); te bao u tao ra
mang li, co cac the Schiller - Duval (mui ten, B); Te bao u san xuat AFP (the cau ai toan,C)
a.4/ CARCINOM EM NUOI (choriocarcinoma):

Carcinom em nuoi dang n thuan ch chiem khong qua 1% u te bao mam, nhng lai la
loai u co o ac tnh rat cao.
ai the: u nho, khong lam tinh hoan to ra nhng gay xuat huyet nhieu va co the hoai t.
Vi the: u cau tao bi 2 loai te bao (Hnh 9):
- Cac n bao nuoi, kch thc eu an, mang te bao ro, bao tng sang; nhan nam
chnh ga . Cac n bao nuoi xep thanh tng dai hoac am.
- Cac hp bao nuoi, kch thc ln, nhieu nhan am mau; bao tng ai toan va co cha
nhieu HCG do te bao san xuat.
Hnh 9: U carcinom em nuoi gay xuat huyet nhieu (A) ; Vi the gom cac am n bao nuoi (1) va hp bao
nuoi (2) (B).
a.5/ U QUAI (teratoma):

Chiem 5-10% u te bao mam. U co the xay ra tre em cung nh ngi ln.
ai the: u thng co kch thc 5-10cm; mat cat khong ong nhat do cau tao u gom
nhieu loai mo khac nhau, co nhng vung hoa boc.
Vi the: tuy theo mc o biet hoa, phan biet 3 loai.
- U quai trng thanh
lanh tnh: thng gap tre
em hn la ngi ln. U cau
tao bi nhieu loai mo trng
thanh xuat phat t ca 3 la
phoi: mo than kinh, mo c,
sun, xng, cac loai bieu mo
phu va bieu mo tuyen. Cac
loai mo khac nhau nay sap
xep lon xon tren nen 1 mo
em si hoac mo niem.
- U quai cha trng
thanh: la u ac tnh, cau tao
bi cac loai mo va te bao
cha trng thanh xuat phat Hnh 10 : Mat cat u quai trng thanh co vung ac va vung thoai hoa
t 3 la phoi nh mo sun non, boc (A) ; vi the co mo than em (1), tuyen (2) va cac bo c trn (3) (B).
cac nguyen bao than kinh...
- U quai trng thanh hoa ac: la u quai trng thanh nhng trong thanh phan cau tao cua
no lai co cha 1 thanh phan ac tnh ro ret nh carcinom te bao gai, carcinom tuyen hoac
sarcom.
Mot iem ang chu y la tre em, u quai thng thuoc dang n thuan va co the lanh
tnh neu vi the la u quai trng thanh; khac vi ngi ln, u quai thng la dang hon hp vi
nhieu u te bao mam khac, cho nen du vi the la loai u quai trng thanh th van c xem nh ac
tnh. (Hnh 10)
b/ U MO EM - DAY SINH DUC (tumor of sex cord - gonadal stroma):

La cac loai u xuat phat t mo em cua tuyen sinh duc nguyen thuy, quan trong nhat la 2
loai sau:
b.1/ U TE BAO LEYDIG (Leydig cell tumor):

U co the xay ra moi la tuoi, nhieu nhat trong khoang 20-60 tuoi. U co the san xuat ra
androgen va estrogen, gay ra trieu chng n hoa tuyen vu hoac day th sm tre em.
Hnh 11: U te bao Leydig(*) co gii han ro, mat cat mau nau (A); tinh the Reinke trong bao tng te bao
u (mui ten, B)
ai the: u co kch thc nho , khoang 1-3 cm ng knh, gii han ro, mat cat mau nau.
Vi the: u cau tao bi cac am te bao ln hnh a giac, nhan tron gia, bao tng ai toan
cha nhieu khong bao va cac hat lipid. Trong khoang 30% cac trng hp, co the tm thay tinh
the Reinke hnh tru ac trng cua te bao Leydig trong bao tng te bao u.
Hau het u te bao Leydig eu lanh tnh; khoang 10% co dien tien ac tnh, cho di can en
hach, phoi, gan va hau het cac trng hp nay eu xay ra ngi ln. (Hnh 11)
b.2/ U TE BAO SERTOLI (Sertoli cell tumor):

U co the san xuat estrogen hoac androgen nhng thng khong u e gay ra day th sm
tre em; mot so trng hp co trieu chng n hoa tuyen vu.
ai the: u co kch thc nho, ng knh t 1-3cm, gii han ro, mat o chac, ac, mau
trang xam hoac vang.
Vi the: u cau tao bi cac te bao dai tng t te bao Sertoli, sap xep thanh cac dai ac
hoac ong tuyen tng t ong sinh tinh cha trng thanh. (Hnh 12)
Hnh 12 : U Sertoli kch thc nho, ac, gii han ro (A) ; te bao u xep thanh ong tuyen hoac dai ac tng t
ong sinh tinh cha trng thanh (B)
Hau het u te bao Sertoli eu lanh tnh; khoang 10% co dien tien ac tnh, cho di can en
hach vung (hach chau, hach canh ong mach chu).
4. Lien he lam sang
U tinh hoan co the gay ra cac trieu chng sau:
- Mot tinh hoan sng to, khong au. Co the co tran dch tinh mac th phat do u.
- Cac trieu chng cua di can theo ng bach huyet, en cac hach canh ong mach chu,
hach trung that va hach tren on, lam cac hach nay sng to; hoac cac trieu chng cua di can
theo ng mau en gan, nao, xng.
- N hoa tuyen vu, gap trong cac u tinh hoan co hoat ong noi tiet nh u te bao Leydig
hoac u te bao Sertoli.
Tuy theo u con khu tru trong tinh hoan hay a lan rong ra ngoai, co the xep vao cac giai
oan lam sang nh sau:
- Giai oan I: u con gii han trong tinh hoan.
- Giai oan II: u di can va hach sau phuc mac di c hoanh.
- Giai oan III: u di can vao hach tren c hoanh: hach trung that hoac hach tren on.
- Giai oan IV: u cho di can en cac tang nh phoi, gan, xng.
oi vi bac s lam sang, ch can phan biet u te bao mam thanh 2 loai, u tinh bao va u te
bao mam khong phai u tinh bao (UTBMKPUTB), bi co s khac biet ro ret ve ac iem lam
sang, phng phap ieu tr va tien lng gia 2 loai nh sau:
- U tinh bao thng gii han trong tinh hoan trong 1 thi gian dai, v vay phan ln benh
nhan (70%) c phat hien sm trong giai oan I. Trai lai, UTBMKPUTB thng c phat hien
tre hn, giai oan II hoac III.
- U tinh bao di can chu yeu theo ng bach huyet, di can theo ng mau trong ch xay
ra trong giai oan muon. Trai lai, UTBMKPUTB (nhat la loai carcinom em nuoi) thng cho di
can sm theo ng mau en phoi, gan
- Ve phng dien ieu tr va tien lng: u tinh bao rat nhay vi xa tr do o tien lng rat
tot; 90% benh nhan giai oan I va II co the c cha khoi hoan toan bang phau thuat cat bo
tinh hoan phoi hp vi xa tr phong nga vao hach canh ong mach chu. Trai lai, UTBMKPUTB
thng e khang vi tia xa do o phai ieu tr phau thuat ket hp hoa tr; tien lng phu thuoc
vao giai oan lam sang cua benh nhan hn la vao dang vi the cua u, nhng nhn chung th xau
hn nhieu so vi u tinh bao.
Chat anh dau sinh hoc la cac hormon va enzym c san xuat trong 1 so loai u te bao
mam ma ta co the nh lng c trong mau benh nhan; ang chu y nhat la HCG (do hp bao
nuoi trong carcinom em nuoi san xuat) va AFP (do te bao u tui noan hoang san xuat); chung
rat co gia tr trong:
- anh gia tong khoi u.
- Xep giai oan lam sang: th du 1 benh nhan b ung th tinh hoan loai carcinom em nuoi
hoac u tui noan hoang giai oan I, HCG hoac AFP phai giam nhanh sau phau thuat cat bo khoi
u tinh hoan. Neu ham lng trong mau van con cao th chng to benh nhan a sang giai oan II,
mac du tren lam sang kham thay hach cha to.
- Theo doi ap ng vi ieu tr: ham lng HCG hoac AFP gia tang tr lai sau ieu tr
chng to benh nhan b tai phat mac du van cha thay bieu hien lam sang.
BENH LY DNG VAT

Dng vat co the b cac d tat bam sinh, viem va u, trong o 2 loai sau la quan trong nhat.
A. D TAT BAM SINH
1. Hep that da qui au
La tnh trang lo da qui au qua nho lam da qui au khong the tuot ra khoi au dng vat
c. Tnh trang nay can tr viec lam ve sinh ca nhan, cac dch tiet va can nc tieu de b tch
tu, tao thuan li cho nhiem trung va ung th dng vat.
2. Tat lo tieu tren va di
Do d dang ranh nieu ao nguyen thuy, a en tnh trang lo tieu m ra mat tren hoac
mat di dng vat. D tat nay thng thay phoi hp vi chng tinh hoan an va cac d tat khac
cua ng tieu, co the gay tac nghen va nhiem trung ng tieu hoac chng vo sinh.
B. VIEM
Dng vat co the b viem do nhieu tac nhan khac nhau, chu yeu trong cac benh hoa lieu
nh giang mai, lau, ha cam mem, herpes sinh duc. Ngoai ra, chng hep that da qui au co the
tao thuan li cho tnh trang viem dng vat do cac vi khuan sinh mu hoac nam.
C. U
U dng vat noi chung t gap, thng gap nhat la condylom va carcinom te bao gai.
1. Condylom sui: la 1 u lanh do HPV gay ra, thng la HPV typ 6 va 11.
ai the: u co dang sui nh bong cai, ng knh vai milimet; thng thay ranh vong au
dng vat va mat trong da qui au.
Vi the: gom cac nhu bieu b tang san tng t u nhu da, ch khac biet cho co them s
hien dien cua cac te bao rong (Koilocyte) trong cac lp pha tren cua bieu b. (Hnh 13)
Hnh 13 : ai the condylom sui (A) ; vi the tng t u nhu da (B) nhng co them te bao rong (mui ten, C)
2. Condylom khong lo: con goi la u Buschke - Lowenstein, cung do HPV typ 6 va 11 gay ra.
ai the: u cung co dang sui nh bong cai nhng kch thc ln vai cm.
Vi the: tng t condylom sui nhng khac cho bieu mo tang san co the xam nhap sau
xuong mo em.
Condylom khong lo de tai phat sau cat bo nhng khong bao gi cho di can. Nh vay,
condylom khong lo co v tr trung gian gia condylom sui hoan toan lanh tnh va carcinom te bao
gai dng vat hoan toan ac tnh.
3. Carcinom te bao gai tai cho (squamous cell carcinoma in situ)

Carcinom tai cho cua dng vat gom co 2 loai:
a/ Benh Bowen (Bowens disease):
ai the: ton thng co dang 1 mang day mau o, ong vay nhe, gii han ro, thng thay
qui au dng vat hoac da qui au.
Vi the: bieu b gom cac te bao d dang, nhan am mau, co hien tng mat phan cc va
tang t le phan bao; tuy nhien mang ay van con nguyen ven.
b/ Benh Hong san Quyerat (erythroplasia of Queyrat):
ai the: ton thng la cac mang mau o bong, gii han khong ro, thng gap au
dng vat hoac da qui au.
Vi the: cung co d dang te bao va mat phan cc, tng t nh benh Bowen. (Hnh 14)
Hnh 14 : Hong san Queyrat (A), Benh Bowen (B), tren vi the la carcinom te bao gai tai cho (C)
Benh Bowen va benh hong san Queyrat thng xay ra ngi ln tuoi, tren vi the eu la
carcinom tai cho, ch khac nhau chut t ve ai the. V vay hien nay, 2 benh c xem la mot vi
tien lng va cach ieu tr giong nhau. Tuy mc o benh, co the ieu tr bang nhieu phng
phap khac nhau nh boi fluorouracil tai cho, ot ien hoac phau thuat.
4. Carcinom te bao gai dng vat

Chiem 3,4 % ung th cua gii nam theo ghi nhan cua Benh vien Ung bu Tp.HCM
(2008), trong o hn 90 % so benh nhan co tien can hep that da qui au hoac co da qui au
qua dai. Tuoi thng gap la 40-70 tuoi.
Hien nay, moi lien quan gia carcinom te bao gai dng vat vi tnh trang hep that da qui
au va nhiem HPV a c chng minh :
- Ung th dng vat hiem gap dan toc Do Thai, von co phong tuc cat da qui au cho tre
trai ngay t khi mi sinh. Tnh trang hep da qui au lam tang nguy c ung th dng vat
trc ay c cho la do ve sinh kem va do cac tac nhan sinh ung cha trong chat can
cua bao qui au (chat smegma); tuy nhien hien nay ngi ta cho rang tac ong bao ve
cua viec cat da qui au la do giup tranh nhiem HPV.
- HPV typ 16 va 18 co the co lien quan en qua trnh sinh ung; bi v cac nghien cu cho
thay t 20-60% cac trng hp ung th dng vat b nhiem 2 typ virus nay.
Hnh thai ton thng:
ai the: ton thng co dang sui hoac loet, thng gap au dng vat hoac ranh qui au
dng vat. Vung sui loet lan rong dan, co the pha huy toan bo au dng vat hoac mot phan
than dng vat.
Vi the: tng t carcinom te bao gai cua da, thng co o biet hoa tot vi s thanh lap
cac cau sng nam gia cac am te bao gai ung th. (Hnh 15)
Hnh 15 : Carcinom te bao gai ranh qui au (A) ; tren vi the la carcinom te bao gai biet hoa tot.
Lien he lam sang: carcinom te bao gai dng vat co dien tien cham tai cho trong nhieu
nam, sau o mi cho di can vao hach ben va hach chau 2 ben. Di can xa ch xay ra trong giai
oan muon. Tien lng tot neu benh nhan c ieu tr giai oan cha co di can hach ben vi
t le song them 5 nam la 66%.
BENH LY TUYEN TIEN LIET

Tuyen tien liet (TTL) hnh non ngc, nam sau phuc mac, bao quanh co bang quang va
nieu ao, ngi trng thanh nang khoang 20g. Ve cau tao giai phau hoc, TTL gom co 3 vung
va 1 ban si-c trn trc. Vung trung tam pha tren, chiem 25% the tch TTL. Vung chuyen
tiep, pha trc-ngoai nieu ao. Vung ngoai vi ln nhat, chiem 70% the tch TTL, pha sau-
ngoai nieu ao. (Hnh 16A)
Ve mat benh ly, co the phan biet TTL thanh 2 vung:
- Vung trong (inner prostate) bao quanh nieu ao, tao bi vung chuyen tiep va ban si-c
trc, la ni xuat phat cua cac tang san dang cuc.
- Vung ngoai (outer zone), tao bi vung trung tam va vung ngoai vi, la ni xuat phat cua
carcinom TTL. (Hnh 16B)
Ve vi the, TTL cau tao bi cac tuyen ong tui phan nhanh, lot bi bieu mo gom 2 lp te
bao: lp ay la cac te bao hnh vuong va lp be mat gom la cac te bao che tiet hnh tru. (Hnh
16C)
Hnh 16 : Cau tao giai phau hoc (A) va phan vung benh ly cua tuyen tien liet (B) ; vi the
Cac dang benh ly thng thay TTL gom: viem, tang san dang cuc va carcinom TTL.
A. VIEM
1. Viem tuyen tien liet cap tnh (acute prostatitis):

Thng do cac vi khuan nh E. Coli va cac vi khuan gram am khac nh Klebsiella,
Proteus. Cac vi khuan nay co the xam nhap trc tiep vao TTL qua nga nieu ao hoac t bang
quang; hoac t 1 o nhiem khuan ni khac (th du ruot) mun ng mau va bach huyet i
en TTL. Viem TTL cung co the xay ra sau 1 so thu thuat nieu khoa nh at ong thong nieu
ao, nong nieu ao, soi bang quang, cat ot noi soi TTL, v.v. Cac trieu chng lam sang gom co
sot, n lanh, tieu gat buot, au nhc vung hoi am.
ai the: TTL sng to, phu ne, sung huyet; co cho b hoai t hoa mu tao thanh cac o ap xe
nho.
Vi the: TTL tham nhap nhieu bach cau a nhan, cac tuyen tang che tiet. Phan ng viem
cap tnh giam dan va c tiep noi bang phan ng tao si hoa seo. Neu cac ong tuyen b tac
nghen hoac khi cac o mu khong dan lu c, tnh trang viem cap de chuyen thanh viem man.
(Hnh 17A,B)
2. Viem tuyen tien liet man tnh (chronic prostatitis)

Cung do cac tac nhan vi khuan gay ra viem TTL cap tnh, gay ra cac trieu chng nh au
lng, tieu lat nhat, tc nang vung hoi am hoac tren xng mu; cung co khi benh nhan hoan toan
khong co trieu chng; e chan oan can phai nuoi cay c vi khuan t cac dch tiet cua TTL.
Tuy nhien phan ln cac viem TTL man tnh hien nay lai cho ket qua nuoi cay am tnh, trng
hp nay c goi la viem TTL man tnh vo khuan (chronic abacterial prostatitis).
ai the: TTL co mat o cng chac hn bnh thng.
Vi the: nhu mo TTL tham nhap nhieu te bao viem man tnh nh limpho bao, tng bao,
ai thc bao. (Hnh 17C)
Hnh 15 : Viem TTL cap tnh, bach cau a nhan tham nhap mo em va ay trong long tuyen (A,B). Viem
TTL man tnh, mo em tham nhap limpho bao, tng bao va ai thc bao(C).
B. TANG SAN TUYEN TIEN LIET DANG CUC (nodular hyperplasia):

Rat thng gap ngi tren 50 tuoi. Ket qua khao sat ngau nhien tren cac trng hp t
thiet cho thay xuat o tang san tien liet tuyen dang cuc (TSTTLDC) ngi 40 tuoi ch co 20%,
tang len 70% ngi 60 tuoi va 90% ngi tren 70 tuoi. S tang xuat o theo tuoi tac khien
co y kien cho rang TSTTLDC khong phai la mot benh ly thc s ma ch la mot bien oi t nhien
do qua trnh lao hoa.
Nguyen nhan: cha ro nguyen nhan gay ra TSTTLDC nhng chac chan co 1 vai tro nhat
nh cua cac noi tiet to nam, bi v benh ly nay ch xay ra nhng ngi con nguyen ven tinh
hoan. Do 1 c che cha ro, dihydrotestosterone tch tu trong TTL va gan len thu the tng ng
trong nhan te bao tuyen, kch thch s tang san cua TTL.
ai the: tuyen tien liet tang san dang cuc co trong lng khoang 60-100 gr. Tren mat cat
thay ro cac cuc tang san tap trung vung trong TTL, chen ep nieu ao thanh 1 khe hep. Cuc
tang san co mat o mem hoac chac, mau hong hoac trang xam.
Hnh 16: Cac cuc tang san tap trung vung trong, chen ep nieu ao (A,B); tuyen tang san tao nhu va boc,
trong long co cha the amylacea (*); tang san mo em si-c trn gia cac tuyen (C).
Vi the:
Cuc tang san cau tao bi 2 thanh phan:
- Cac tuyen tang san tao nhu, boc. Tuyen c lot bi bieu mo gom 2 lp te bao, trong
long tuyen co cha nhieu the amylacea (do chat tiet co ac lai tao thanh), the nay co the b lang
ong calci thanh soi TTL.
- Mo em si - c trn tang san.
Lien he lam sang:

Nieu ao b chen ep bi cac cuc tang san lam benh nhan tieu kho hoac b tieu. Nc tieu
lai co the gay gian bang quang, than nc, viem than va suy than.
C. CARCINOM TUYEN TUYEN TIEN LIET (adenocarcinoma of the prostate):
Thng xay ra ngi > 50 tuoi. Ghi nhan ung th trong khoang thi gian t 2004 en
2008 tai Benh vien Ung Bu Tp.HCM va Benh vien K Ha noi cho thay ung th TTL ng th 7
va th 9 trong 10 loai ung th thng gap gii nam,
Nguyen nhan: cha ro nhng chac chan co vai tro cua cac noi tiet to nam trong s phat
trien cua carcinom TTL; bang chng la ung th nay khong bao gi xay ra ngi a b thien
hoan trc tuoi day th. Ung th nay cung t gap nhng ngi co tnh trang tang estrogen (th
du do x gan).
Hnh thai ton thng
ai the: phan ln ung th xuat phat t
vung ngoai cua TTL, nhat la mat sau (nh vay
co the phat hien qua tham kham trc trang). U co
mau trang xam hoac vang nhat, mat o chac, gii
han khong ro, tren mat cat co the thay nhieu o
hoai t. (Hnh 17):
Vi the: thay oi tuy theo mc o biet hoa.
- o biet hoa tot: u cau tao bi cac tuyen
nho ong dang nam chen chuc nhau; tuyen ch
c lot bi 1 lp te bao (thay v 2 lp nh bnh
thng). Te bao co nhan ln, tang sac, hach
nhan ro, bao tng co the lt hoac am mau hn
Hnh 17: O ung th nam trong vung ngoai TTL.
bnh thng.
- o biet hoa va: te bao ung th xep thanh cac tuyen to nho khong eu, meo mo, co
dang sang.
- o biet hoa kem: te bao ung th xep thanh cac be hoac am ac, thng co hoai t
trung tam.(Hnh 18)
Hnh 18: Carcinom TTL biet hoa tot (A); biet hoa va (B); biet hoa kem,te bao u xep thanh am ac (C); biet
hoa kem co hoai t trung tam (*) ,D)
Lien he lam sang:

Ung th TTL co the lan rong theo nhieu cach:
- Xam nhap trc tiep qua vo bao vao tui tinh va ay bang quang, co the gay tac nghen
nieu quan.
- Di can theo ng bach huyet en cac hach vung chau va hach canh ong mach chu.
- Di can theo ng mau en xng (thng la xng song, xng ui, xng sn), t
thay di can vao cac tang.
Ung th TTL co the ch bieu hien tren lam sang bang cac trieu chng tac nghen ng
tieu hoac cac trieu chng au do di can xng. Benh c chan oan bang cach tham kham
TTL qua trc trang, sinh thiet bang dao hoac choc hut bang kim nho e tm cac te bao ac tnh.
e chon la ieu tr va anh gia tien lng,
T
benh nhan c xep giai oan lam sang theo he
thong TNM: oi vi giai oan T1 va T2, phau thuat T1: Cha phat hien u tren lam sang
cat bo TTL c ket hp vi xa tr; giai oan T3 va T2: U gii han trong TTL
T4, xa tr ket hp cac bien phap loai bo noi tiet to
T3: U xam lan ra ngoai vo bao TTL,
nam lu thong trong mau (cat tinh hoan hoac dung
xam nhap vao tui tinh
thuoc). T le song sot 5 nam c ghi nhan la 90%
oi vi benh nhan giai oan T1 va T2, 40% vi giai T4: U xam lan vao cac cau truc khac
oan T3 va ch con 10% vi giai oan T4. N
Tuy ung th TTL thng dien tien rat cham N0: Cha co di can hach
nhng co en 75% benh nhan khi c phat hien th
N1: Co di can hach vung
a vao giai oan T3 va T4. V vay e giam t le t
vong, can phai tam soat phat hien sm bang cach M
nh lng 1 khang nguyen ac hieu cua TTL la M0: Cha co di can xa
PSA (prostate - specific antigen) va tham kham nh
M1: Co di can xa
ky TTL cho nhng ngi 50 tuoi.
PSA la mot serine protease c san xuat bi cac te bao bieu mo TTL bnh thng cung
nh cac te bao u TTL. Ham lng trong mau cua PSA rat thap ngi bnh thng (< 4
nanogram/ml), tang nhe ngi b tang san dang cuc TTL va tang cao ngi b ung th TTL (
> 10 nanogram/ml)
Nh vay, PSA la 1 chat anh dau sinh hoc, co gia tr:
- Tam soat, gi y kha nang co ung th TTL.
- anh gia ket qua ieu tr, PSA phai giam sau cat bo khoi u.
- Phat hien di can, PSA tang lai mot thi gian sau khi ieu tr.
1. ieu nao trong viem tinh hoan do quai b sau ay KHONG ung:
A/ Benh nhiem virus toan than, thng ngi ln.
B/ Xuat hien sau viem tuyen mang tai khoang 1 tuan.
C/ Tinh hoan sng to va au do phu ne trong mo ke
D/ Vi the co hien tng phu viem va tham nhap te bao n nhan.
E/ Hoai t cac ong sinh tinh gay vo sinh ve sau.
2. Tat tinh hoan an:

A/ Thng b ca hai ben, phai va trai
B/ V tr tinh hoan an trong o bung chiem t le cao nhat
C/ Cac ong sinh tinh trong tinh hoan an cha toan te bao Sertoli, mang ay bao quanh
rat day
D/ Khong lam tang nguy c ung th tinh hoan
3. U nao sau ay thuoc nhom u mo em - day sinh duc tinh hoan:

A/ U te bao vo B/ Carcinom em nuoi C/ U tinh bao.
D/ U te bao Sertoli E/ U quai cha trng thanh
4. AFP trong mau dng tnh trong:

A/ Carcinom te bao gan B/ U tui noan hoang tinh hoan
C/ U tui noan hoang buong trng D/ Ch B, C ung
E/ Tat ca A, B, C ung
5. Mot benh nhan nam 30 tuoi, co khoi u nghi ng ac tnh, xam chiem toan bo tinh hoan. Chup
CT cho thay khoi u co mat o ong nhat; ham lng HCG va AFP trong mau benh nhan khong
tang, nhieu kha nang ay la u:
A/ U tinh bao B/ U tui noan hoang C/ U te bao Leydig
D/ U quai trng thanh E/ Carcinom em nuoi
6. PSA la 1 chat anh dau sinh hoc rat co gia tr trong ung th tuyen tien liet, bi v:
A/ PSA ch c san xuat bi cac te bao bieu mo TTL a chuyen dang thanh te bao u
B/ Giup anh gia ket qua ieu tr, PSA phai giam sau cat bo khoi u.
C/ Giup phat hien di can
D/ Tat ca A, B, C ung E/ Ch B va C ung
7. Carcinom te bao gai dng vat:

A/ Co moi lien quan vi tnh trang hep da qui au
B/ Ve vi the u thng co o biet hoa kem
C/ Cho di can en di can hach ben 2 ben
8. Tang san dang cuc tien liet tuyen:

A/ t gap ngi tren 70 tuoi
B/ Tuyen tien liet to, mat cat co cac o hoai t xuat huyet.
C/ Nieu ao b chen ep tao thanh 1 khe hep
D/ V tr thung ngoai vi tuyen tien liet
E/ Cac tuyen c lot bi lp bieu mo co 1 hang te bao tang san tao nhu.
Benh ly Than 287
BENH LY THAN
Muc tieu :
1. Mo ta va phan tch ton thng trong benh cau than nguyen phat.
2. Mo ta va phan tch ton thng cau than trong benh lupus o he thong.
3. Mo ta va phan tch ton thng cau than trong benh tieu ng.
4. Mo ta va phan tch cac ton thng trong viem ong than - mo ke.
5. Mo ta va phan tch cac ton thng trong hoai t ong than cap.
6. Mo ta va phan tch cac ton thng than trong cao huyet ap lanh tnh va ac tnh
7. Ke ten ton thng than trong soi than
8. Mo ta ton thng thai ghep than
9. Ke ten cac loai u than.
10. Mo ta va phan tch cac ton thng trong carcinom te bao than.
11. Mo ta va phan tch cac ton thng trong u Wilms.
12. Mo ta va phan tch cac ton thng trong carcinom te bao chuyen tiep be than.
Hai than hnh hat au, nam canh cot song va sau phuc mac. Than ngi ln nang
khoang 150g, dai 11 cm, rong 6 cm va day 3 cm. Cau tao moi than gom 2 vung: vo than
ngoai va ben trong la tuy than. n v cau tao ve hnh thai va chc nang cua than c goi la
n v than (nephron), gom co cau than va cac ong than, c bao quanh bi mo ke than cha
nhieu mach mau; am nhan cac chc nang quan trong: loc mau, tai hap thu co chon loc nc
va mot so chat hoa tan giup duy tr can bang noi moi (can bang nc-dien giai, thang bang
kiem toan), bai tiet chat can ba va cac chat oc. (Hnh 1 va 2)
Hnh 1 : S o cau truc 3 chieu cau than bnh thng va cac thanh phan lien quan mang loc cau than
Benh ly Than 288
Benh ly than c chia thanh 4 nhom chnh theo cau tao vi the la benh cau than,
benh ong than, benh mo ke va benh mach mau. Ngoai ra con cac benh ly khac nh benh than
ghep, soi than, u than va mot so benh t gap nh d tat bam sinh (nghch san than, than hnh
mong nga), than a nang Cac benh ly than khac nhau eu co the dan en suy than cap hay
suy than man. Trong chan oan benh than, ngi ta thng s dung phng phap sinh thiet
than (bang kim qua da di hng dan sieu am hay bang phau thuat).
Suy than cap la tnh trang suy giam ot ngot chc nang than: toc o loc cau than giam
nhanh, hau qua la ure mau tang cao kem trieu chng thieu nieu hoac vo nieu. Nguyen nhan
gay suy than cap co the : trc than nh suy giam the tch tuan hoan do mat nc, mat mau,
suy tim cap, soc; tai than do cac benh gay ton thng cau than, ong than, mo ke hoac mach
mau than nh viem cau than tien trien nhanh, cao huyet ap ac tnh, hoai t nhu than cap kem
viem than - be than cap, viem ong than mo ke do thuoc, hoai t lan toa vo than; sau than nh
tac nghen ng tieu thap.
Suy than man la tnh trang suy giam man tnh chc nang than, ure mau dan dan tang
cao, gay ton thng nhieu c quan nh xng (loan dng xng do than), tim-phoi (viem
mang ngoai tim, viem mang phoi), he tao mau (thieu mau), da day - ruot (viem da day ta trang,
oi khi gay xuat huyet tieu hoa). Suy than man la dien tien cuoi cung cua cac benh than man
tnh.
BENH LY CAU THAN
Hnh 2: S o cau tao va cau truc cua cau than bnh thng
Viem cau than (glomerulonephritis) va benh cau than (glomerulopathy) la hai t cung
c s dung e ch cac ton thng cau than. Tuy nhien, mot so tac gia ch dung t viem cau
than cho nhng trng hp ton thng cau than co kem phan ng viem.
Benh cau than co the nguyen phat hoac th phat. Benh cau than co ton thng khu tru
cau than c goi la benh cau than nguyen phat; cac bieu hien toan than khac (nh cao
huyet ap, cac trieu chng do tang ure-mau,) ch la hau qua cua tnh trang roi loan chc nang
cau than. ai a so cac benh cau than la nguyen phat; va trong hau het cac trng hp, benh
cau than nguyen phat thng vo can. Benh cau than c goi la th phat khi ton thng cau
than la mot phan cua mot benh ly a he thong.
Benh ly Than 289
Da tren dien tien lam sang, benh cau than cung co the c chia thanh: cap tnh,
ban cap (hoac tien trien nhanh) va man tnh.
Benh cau than co the bieu hien tren lam sang bang cac hoi chng sau:
1. Tieu mau khong au tng t, co nhieu mc o: tieu mau ai the hoac tieu mau
vi the.
2. Tieu am khong trieu chng
3. Viem than cap: tieu mau, thieu nieu va cao huyet ap.
4. Hoi chng than h: tieu am > 3,5g/24 gi, albumin-mau giam, phu toan than,
thng kem tang lipid-mau
5. Suy than man
Nhieu benh cau than khac nhau co the co cung mot bieu hien lam sang; ngc lai, mot
benh cau than co the bieu hien tren lam sang bang nhieu hoi chng khac nhau.
Hnh thai ton thng chung (Hnh 3):
Cho du la nguyen phat hay th phat, benh cua cau than co chung cac hnh thai ton
thng sau:
1. Tang sinh (proliferative) khi co tang so lng te bao cau than do tham nhap cac
bach cau a nhan va ai thc bao hoac do tang sinh cac te bao cau than (te bao
gian mao mach, te bao noi mo, te bao bieu mo).
2. Bien oi mang (membranous) khi mang ay cac mao mach cau than day len.
3. Tang sinh mang (membranoproliferative) khi phoi hp ca hai ac iem tren
4. Liem (crescentic) khi co tang san manh cac te bao bieu mo la ngoai bao Bowman
kem tham nhap cac mono bao, tao thanh mot liem te bao, e ep cac bui mao mach
cua cau than.
5. Hoa x (sclerosis) khi co tang so lng chat ngoai bao co cau truc va thanh phan
hoa hoc tng t mang ay va chat nen cua mo em gian mao mach.
Cac ton thng nay co the: lan toa khi 50% cau than b ton thng; khu tru khi < 50%
cac cau than b ton thng; toan bo khi hau het cac quai mao mach cau than eu b ton thng;
hoac mot phan khi ch co mot so quai mao mach cau than b ton thng (Hnh 4).
e chan oan chnh xac benh ly cau than, ngoai phng phap nhuom thng quy
Hematoxylin-eosin, thng phai can en cac phng phap nhuom ac biet ( PAS, Trichrome,
nhuom bac) va mien dch huynh quang, co khi ca knh hien vi ien t.
Hnh 3 : Cac hnh thai ton thng cau than Hnh 4 : Mc o ton thng cau than
Benh ly Than 290
I. CAC BENH CAU THAN NGUYEN PHAT THNG GAP
A. Benh cau than ton thng toi thieu (Minimal change glomerulopathy):
Benh cau than ton thng toi thieu la nguyen nhan gay hoi chng than h thng gap
nhat tre em. Tuoi thng gap la 2-6 tuoi.
C che benh sinh cha ro, co the do roi loan chc nang mien dch dan en san xuat
cytokine lam hong chan cua tuc bao, ket qua benh nhan tieu ra protein.
- Di knh hien vi quang hoc, cau than co ve bnh thng. Te bao ong ln gan ong
lipid va protein (do co tai hap thu cac lipoprotein thoat vao dch loc cau than).
- Di knh hien vi ien t, co s xoa chan cac tuc bao, lam te bao nay nh b ap chat
len mang ay. Ton thng cua tuc bao co the hoi phuc sau ieu tr bang corticoid.
Lien he lam sang: Benh bieu hien tren lam sang bang hoi chng than h, xay ra tren tre khoe
manh, khong kem cao huyet ap, chc nang than bnh thng. Tieu am co chon loc, chu yeu la
albumin. Benh tre em co tien lng tot. ieu tr bang corticoid, 90% benh nhan co ap ng;
tuy nhien 2/3 benh nhan se b tieu am tai phat. Khoang 5% se dien tien ti suy than sau 25
nam. Benh ngi ln co ap ng vi ieu tr bang corticoid, nhng t le tai phat cao hn. Neu
benh nhan co trieu chng tang ure mau th co kha nang a b x hoa cau than mot phan-khu
tru hoac b ton thng toi thieu kem viem than-mo ke do thuoc.
Hnh 5 : S o benh cau than ton thng toi thieu (A); Cau truc cau than van bnh thng, ch co tuc bao b
mat chan, nhuom PAS (B); tnh trang mat chan thay ro di KHVT (C)
B. X hoa cau than mot phan khu tru (Focal segmental glomerulosclerosis, FSGS):
X hoa cau than mot phan-khu tru co the xuat hien:
- Nguyen phat va thng la vo can.
- Th phat sau mot so benh ly tai than hoac ngoai than nh tnh trang giam tong khoi
nhu mo than bam sinh ( vo tao 1 than) hoac mac phai ( trong benh than trao ngc), benh tim
bam sinh tm, nhiem HIV, dung thuoc Pamidronate.
Bat ke nguyen nhan nao, trong benh x hoa cau than mot phan-khu tru, luon thay co ton
thng cac tuc bao. Cau than b x hoa tng phan la do hien tng tang tnh tham oi vi cac
protein va lipid huyet tng, dan en tnh trang lang ong hyalin trong mo em gian mao mach.
- Ton thng khu tru mot so cau than, va moi cau than ch co mot so cac quai mao
mach b ton thng x hoa, cac quai mao mach khac van bnh thng. Vung x hoa co the
gan cc mach, cc nieu va co the dnh vao bao Bowman. Mo em gian mao mach tang kch
Benh ly Than 291
thc do lang ong chat hyalin .
- Khao sat di knh hien vi huynh quang cho thay co lang ong IgM va bo the C3 trong
vung gian mao mach va phan cau than x hoa. (Hnh 7)
- Khao sat di knh hien vi ien t cho thay co hien tng xoa chan lan rong cua cac
tuc bao; co cho tuc bao b bong troc e lo mang ay ben di.
Khi benh dien tien lau ngay toan bo cau than b x hoa, teo ong than va x hoa mo ke,
luc o kho phan biet c vi cac dang viem cau than man.
Hnh 6: X hoa cau than mot phan, dnh loi cau than vao Hnh 7: Lang ong IgM phan cau than
bao Bowman. x hoa va vung gian mao mach
(nhuom mien dch huynh quang)
Lien he lam sang: Benh x hoa cau than mot phan-khu tru la nguyen nhan cua 30%
trng hp hoi chng than h ngi ln va 10% tre em. Benh khi au bang tnh trang tieu
am am tham; nhieu benh nhan co kem tieu mau va cao huyet ap. Can phan biet vi hoi chng
than h gay ra bi benh cau than ton thng toi thieu v dien tien lam sang cua hai loai rat khac
nhau. Benh x hoa cau than mot phan-khu tru thng gay tieu am dai dang, ap ng kem vi
ieu tr bang corticoide. 50% benh nhan dien tien ti suy than trong vong 10 nam; ngi ln co
tien lng xau hn tre em.
C. Viem cau than hau nhiem trung cap tnh (Acute post-infectious glomerolunephritis):
Viem cau than hau nhiem trung cap tnh thng co dang viem cau than tang sinh lan
toa (diffuse proliferative glomerulonephritis); ay la 1 ton thng cau than cap tnh theo sau mot
benh nhiem khuan. Thng gap nhat la viem hong, viem da do nhiem lien cau khuan tan huyet
nhom A. Cac loai vi khuan khac co the gap gom: tu cau khuan, vi khuan nao mo cau, phe cau
khuan, virus, sot ret, nhiem toxoplasma, nhiem schistosomia. Benh khi phat khoang 10 ngay
sau viem hong hoac viem da do lien cau khuan.
C che: khang the gan len cac khang nguyen vi khuan tao thanh phc hp mien dch
lang ong chu yeu di chan tuc bao va tren mang ay cau than.
- Tat ca cac cau than eu b ton thng. Cac cau than phnh to, giau te bao do s tang
sinh cua te bao gian mao mach, te bao noi mo va te bao bieu mo. Te bao noi mo phong to. Cau
than tham nhap cac bach cau a nhan trung tnh; trong mot so trng hp nang, cau than co
liem te bao. Mo ke phu, tham nhap t te bao viem. Ong than cha cac tru hong cau, bieu mo
ong than b thoai hoa.
- Di knh hien vi huynh quang thay co lang ong IgG va C3 doc theo mang ay mao
mach cau than va trong mo em gian mao mach, trong giong hnh anh bau tri ay sao.
- Di knh hien vi ien t, phc hp mien dch lang ong di bieu mo la trong trong
giong nhng go at (hump), chan tuc bao hi b xoa i.
Lien he lam sang: Benh thng gap tre nho 6-10 tuoi. T 1-2 tuan le sau viem hong,
Benh ly Than 292
tre co trieu chng met moi, sot, buon non, tieu t, tieu mau hoac nc tieu sam mau, phu
mat nhat la quanh hoc mat, cao huyet ap nhe. Trng hp viem cau than hau nhiem lien cau
khuan cap tnh, co tang anti-streptolysin va giam C3 trong mau. Phan tch nc tieu thay co
mau, bach cau, tru va t hoac nhieu am nieu. Benh xay ra tre em co tien lng tot, trai lai
ngi ln ch co 60% khoi benh hoan toan. Neu co kem theo ton thng liem te bao, tien lng
benh se xau i.
Hnh 8: Viem cau than hau nhiem trung, cau than viem tang sinh toan bo, phnh to, tham nhap nhieu bach
cau a nhan trung tnh (A); nhuom mien dch huynh quang cho thay co s lang ong bo the C3 thanh cac
quai mao mach va vung gian mao mach (hnh anh bau tri sao) (B); phc hp mien dch lang ong di bieu
mo la trong trong giong nhng go at (C).
D. Benh cau than mang (Membranous glomerulopathy):

La ton thng cau than gay hoi chng than h thng gap ngi ln. 85% trng hp
la benh vo can; so con lai th phat sau nhiem trung (viem gan sieu vi B hoac C man tnh, giang
mai, sot ret), lupus o he thong, tiep xuc vi muoi vo c (muoi vang, thuy ngan), do thuoc
(penicillamine, captopril), ung th (ac biet la carcinom phoi, ai trang va melanom).
C che benh sinh: Do lang ong cac phc hp mien dch lu thong trong mau len mang
ay cau than. Trong cac trng hp vo can, cac khang the tng tac tai cho vi cac khang
nguyen noi sinh hoac cac khang nguyen gan tren cau than.
Hnh thai ton thng:
- Di knh hien vi quang hoc ch thay hnh anh thanh mao mach day len, co dang gai,
lo, khong kem tang san te bao (tr ton thng than do lupus ban o).
- Di knh hien vi huynh quanh thay hnh anh lang ong dang hat cac IgG va C3 doc
theo thanh mao mach. (hnh 9)
Benh ly Than 293
Hnh 9 : Viem cau than mang: A. Mang ay cau than day va khong co tang sinh te bao (nhuom PAS);
B. Mang ay tao "gai" tng ng giai oan II (nhuom bac); C. Chat lang ong hoa nhap vao
mang ay, tng ng giai oan III; D: Nhuom huynh quang cho thay lang ong dang hat cac
IgG (va tng t oi vi C3) doc theo mang ay.
- Khao sat bang knh hien vi ien t cho thay s lang ong phc hp mien dch dien tien
qua 4 giai oan: (Hnh 9C, 10)
Hnh 10: Cac giai oan lang ong phc hp mien dch trong benh cau than mang
Giai oan I: Chat lang ong nam di tuc bao pha tren mang ay, , mot so tuc bao b mat
chan, mang ay cha nho len.
Giai oan II: Mang ay cau than nho len tao gai bao quanh chat lang ong. Tuc bao mat
chan lan rong.
Giai oan III: Mang ay boc kn chat lang ong va day them.
Giai oan IV: Chat lang ong c pha loang trong mang ay con day.
Khi benh tien trien xa, Cac chat lang ong c chuyen hoa e lai nhng hoc
trong, sau o c lap i bi mot chat giong nh mang ay. Cau than se b x
hoa dan.
Benh ly Than 294
Lien he lam sang: Benh thng gap ngi ln, khoang 30-50 tuoi. Nam mac benh
nhieu hn n. Benh tien trien am tham. Benh nhan co hoi chng than h, tieu am khong chon
loc: mat ca albumin va globulin. Benh thng khong ap ng vi ieu tr bang corticoid. Mac du
60% benh nhan co trieu chng tieu am keo dai nhng ch co 40% trng hp dien tien ti suy
than do x hoa cau than trong vong t 2 en 20 nam.
D. Viem cau than mang - tang sinh (Membranoproliferative glomerulonephritis):

Viem cau than mang - tang sinh co hnh anh benh hoc ac trng la s tang sinh te bao
gian mach cau than, lang ong di noi mo mao mach va hnh anh vien oi mang ay cau
than, bat thng ve bo the C3 va thng giam nong o C3 trong huyet thanh.
Viem cau than mang - tang sinh c chia thanh hai typ chnh la I va II da tren s khac
biet sieu cau truc, mien dch huynh quang va benh sinh. a so viem cau than mang - tang sinh
thuoc ve typ I, typ II tng oi hiem gap. Typ I thng xay ra th phat sau nhiem trung, benh t
mien, co phc hp mien dch tuan hoan, khoi u hoac nguyen phat (khong ro nguyen nhan). Typ
II lien quan en cac bat thng ve hoat ong cua he thong bo the va co the co vai tro cua yeu
to di truyen.
Hnh thai ton thng:

- Di knh hien vi quang hoc, typ I va II co hnh thai ton thng giong nhau: tang san te
bao gian mao mach, tham nhap bach cau, mang ay day len lam noi bat cau truc tieu thuy cua
cau than. Thanh mao mach cau than co hnh anh vien oi (double-contour) thay ro khi nhuom
bac hoac nhuom PAS. Hnh anh nay do cac te bao gian mao mach tho cac nhanh bao tng
cua chung chen vao gia cac quai mao mach. (Hnh 11)
Hnh 11 : S o va hnh anh sieu vi the cua viem cau than-mang tang sinh typ I (A1,A2), typ II (B1,B2).
mang ay cau than day va dang vien oi thay ro tren phep nhuom bac. Cau truc tieu thuy noi bat do
mang ay day len (C). Hnh anh vien oi (mui ten) khi nhuom bac (D).
- Di knh hien vi huynh quang va knh hien vi ien t, typ I va II co hnh anh ton thng
khac nhau:
Benh ly Than 295
* Typ I: lang ong di te bao noi mo 1 chat am ac cau tao bi C3, IgG va mot t
C1q, C4.
* Typ II: lang ong trong mo em gian mao mach va gia mang ay mot chat am ac
khong ro thanh phan cau tao, lam mang ay b bien dang giong hnh dai ru bang. Co the thay
C3 trong mang ay nhng khong co trong chat am ac; thng khong thay IgG, C1q va C4.
Lien he lam sang: bieu hien lam sang co the la hoi chng than h hoac viem than cap
hoac ch la tnh trang tieu am khong trieu chng. Tien lng xau, 40% benh nhan dien tien ti
suy than, 30% b giam chc nang than, 30% b hoi chng than h dai dang. Typ II co tien lng
con xau hn, benh co the tai phat ngay tren than ghep.
E. Benh than IgA (benh Berger):

La loai viem cau than thng gap. Benh sinh khong ro. Benh nhan co tnh trang tang
IgA trong mau do roi loan san xuat IgA, xay ra sau mot nhiem khuan ng ho hap hoac tieu
hoa. IgA va cac phc hp mien dch cha IgA lang ong vung gian mao mach, gay ra ton
thng cau than.

- Di knh hien vi quang hoc: co tang sinh cac te bao gian mao mach trong mo em
gian mao mach cua cau than. Ton thng co the khu tru hoac lan toa. Trng hp benh nang,
co hnh anh x hoa mot phan cau than, hoac tao liem te bao.
- Di knh hien vi huynh quang: lang ong IgA va C3 di dang hat tho trong vung gian
mao mach cau than.
- Di knh hien vi ien t: mo em gian mao mach tang kch thc do s tang sinh te
bao gian mao mach. Co s lang ong chat am ac vung gian mao mach.
Lien he lam sang: benh thng xay ra ngi tre, t 15 en 30 tuoi; nam b nhieu hn
n (t le 2:1). Benh thng xuat hien sau 1 nhiem trung ho hap tren, benh nhan co trieu chng
tieu mau (vi the hay ai the) keo dai , co the giam bt roi lai tai phat sau vai thang. tre em
benh dien tien nhe nhang; ngi ln benh tien trien t t, nhng sau 20 nam co en 50% b
suy than.
Hnh 12 : Trong benh cau than IgA, co s tang sinh mo gian mao mach (nhuom PAS) (A,B); Nhuom mien
dch huynh quang, lang ong IgA vung gian mach cau than.
F. Viem cau than man (Chronic glomerulonephritis):

Viem cau than man la giai oan cuoi cua nhieu loai benh cau than khac nhau. Tuy
nhien, cung co nhng benh nhan b viem cau than man ma khong co tien can benh cau than
trc o; ay la nhng trng hp viem cau than khong trieu chng, benh dien tien am tham
en viem cau than man.
Benh ly Than 296
Hnh thai ton thng:

- ai the: Than teo oi xng hai ben,
be mat rai rac nhieu hat. Vo than
mong. Tang mo m quanh be than.
- Vi the: Cau than x hoa, bien thanh

nhng khoi cau hyalin, ai toan, khong
co te bao. Ong than teo. Mo ke hoa si
va tham nhap te bao viem. Cac tieu
ong mach b x cng. giai oan
sm, co the con thay hnh anh ton
thng cua cac benh cau than trc
Hnh 13 : Trong viem cau than man, cau than x hoa, bien
o. (Hnh 13)
thanh nhng khoi cau hyalin mau xanh (nhuom trichrome)
II. CAC BENH CAU THAN TH PHAT

A. Viem than trong benh lupus ban o he thong
Benh lupus ban o he thong la mot benh t mien, thng xay ra phu n tre, benh bieu
hien nhieu c quan (da, khp, than,). Cac ton thng than trong benh lupus ban o he thong
rat a dang, do o bieu hien tren lam sang cung rat phong phu: tieu mau vi the hay ai the tai
phat, hoi chng viem than, hoi chng than h, cao huyet ap va suy than man.
C che benh sinh: Trong benh lupus ban o he thong, cac te bao limpho B hoat ong
qua mc, san xuat ra cac t khang the chong lai ADN, ARN, nucleoprotein va phospholipid.
Cau than b ton thng do lang ong cac phc hp mien dch lu thong trong mau hoac do
phan ng gia cac khang the lu hanh trong mau vi cac khang nguyen nhan (nuclear antigen)
tren mang ay cau than. Phc hp mien dch gom chu yeu la IgG, nhng cung co cha IgA,
IgM, C3, C1q va cac thanh phan bo the khac.
Hnh thai ton thng:
Cac ton thng xay ra chu yeu cau than, c phan thanh 6 nhom theo bang phan
loai nam 2003 cua Hiep hoi Than hoc quoc te va Hoi Benh hoc than (International Society of
Nephrology / Renal Pathology Society) :
Nhom I - Viem cau than lupus co ton thng vung gian mao mach toi thieu : cau than co hnh
anh bnh thng di knh hien vi quang hoc, nhng co lang ong phc hp mien dch trong
vung gian mao mach quan sat c bang phng phap mien dch huynh quang.
Nhom II - Viem cau than lupus tang sinh vung gian mao mach : lang ong phc hp mien dch
van con gii han trong vung gian mao mach nhng a gay ra s tang sinh te bao gian mao
mach lam vung gian mao mach gian rong.
Nhom III - Viem cau than lupus khu tru: ton thng ch xay ra di 50% tong so cau than.
Trong cau than ton thng, lang ong phc hp mien dch trong vung gian mao mach a tran
vao vung di te bao noi mo, gay ra phan ng viem, kch thch s tang sinh te bao noi mo va te
bao gian mao mach.
Nhom IV - Viem cau than lupus lan toa: ton thng giong nh nhom III, nhng xay ra tren 50%
tong so cau than. Ton thng trong moi cau than co the toan bo (phan nhom IV-G) hoac ch
mot phan (phan nhom IV-S). Nhom IV gap trong 60% benh lupus co sinh thiet than. (Hnh 14)
Nhom V Viem cau than lupus mang: lang ong phc hp mien dch tap trung chu yeu trong
vung di te bao noi mo, tuy van con thay trong vung gian mao mach. Hnh anh vi the giong
nh trong benh cau than mang vo can
Benh ly Than 297
Nhom VI Viem cau than lupus x hoa tien trien: tren 90% cau than b x hoa toan bo, dan
en suy than man.
Benh nhan co the co ton thng ket hp gia nhom III va nhom V, hoac nhom IV vi
nhom V. Ngoai viec phan nhom, can phai tnh en ch so hoat ong (tang sinh trong mao mach,
v nhan, liem te bao, viem ong than - mo ke ) va ch so man tnh (x hoa cau than, x hoa mo
ke) e co the tien lng va anh gia ieu tr chnh xac hn. Nhom III va nhom IV co tien lng
xau nhat, can c ieu tr bang corticoid lieu cao va thuoc c che mien dch.
Viem than trong benh lupus o he thong luon co viem mo ke than kem theo, mc o
viem tuy thuoc vao mc o lang ong cac phc hp mien dch trong mo ke.
Ton thng than co y ngha tien lng quan trong trong benh lupus ban o he thong
bi v 1/3 benh nhan lupus ban o b t vong la do suy than.
Hnh 14 : Viem cau than do lupus, nhom IV; thanh mao mach day len do lang ong mien dch, te bao noi mo
va te bao gian mao mach tang sinh trong toan bo cau than (A); nhuom mien dch huynh quang cho thay lang
ong IgG trong thanh mach va vung gian mao mach (B); di KHVT (C), lang ong phc hp mien dch
trong vung di noi mo (1) va trong vung gian mao mach (2).
B. Benh than do tieu ng

Ton thng cau than do tieu ng nam trong nhom cac ton thng do benh ly vi mach.
Hai c che lien quan vi ton thng cau than benh nhan tieu ng la:
- Roi loan chuyen hoa lam day mang ay va tang kch thc mo em gian mao mach.
- Roi loan huyet ong lam ph ai cac cau than.
Co 3 hnh anh ton thng theo mc o benh nang dan
- Ton thng sm (xuat hien sau 2 nam b tieu ng phu thuoc insulin): mang ay mao
mach day len.
- X hoa cau than lan toa: cau than to ra, mo em gian mao mach tang kch thc va
mang ay day len do lang ong mot chat giong mang ay,nhuom PAS dng tnh. Khong co
lang ong cac phc hp mien dch.
- X hoa cau than dang not: trong cau than co mot hoac nhieu not tron, ong nhat, ai
toan, nhuom PAS dng tnh, nam gia cac quai mao mach, goi la not Kimmelstiel-Wilson;
(ay la hnh anh ac trng cua ton thng than do tieu ng). Phan cau than con lai va cac
cau than khac co hnh anh ton thng x hoa lan toa.
Benh ly Than 298
Hnh 15 : X hoa cau than dang not trong benh than do tieu ng, cac not Kimmelstiel-Wilson
bat mau tm o (*) vi phng phap PAS.
Lien he lam sang: Khi au benh nhan ch co tieu am nhe. Khi a co tieu am, du co
kiem soat c ng huyet cung khong the ngan chan c dien tien benh thanh x cng
than. Tieu am thng i kem vi cac bieu hien benh ly vi mach khac nh benh vong mac do
tieu ng. Benh dien tien en suy than trong vong 6 nam.
C. Viem cau than tien trien nhanh (Rapidly progressive glomerulonephritis) :

Ve mo benh hoc la viem cau than liem the (crescentic glomerulonephritis) do trong viem
cau than tien trien nhanh, phan ln cac cau than co tnh trang tang sinh te bao bieu mo tao
thanh cac liem te bao di bao Bowman.
Viem cau than liem the i kem vi cac ton thng khac cua cau than. Co the chia ra 3
nhom:
- Typ I: co lang ong tren mang ay t khang the IgG khang mang ay cau than. Mot so
trng hp, cac t khang nay cung gan c vi mang ay mao mach phe nang, lam benh
nhan co them trieu chng xuat huyet phoi ben canh suy than, goi la hoi chng Goodpasture.
- Typ II: la bien chng cua cac viem cau than do lang ong phc hp mien dch (viem
cau than hau nhiem trung, lupus, benh than IgA).
- Typ III: con goi la typ ngheo mien dch (pauci-immune type) do khong tm thay c
lang ong cua khang the khang mang ay hoac phc hp mien dch nh 2 typ tren. Trong huyet
thanh cua hau het benh nhan, co khang the ANCA (antineutrophil cytoplasmic antibody) chong
cac protein co trong bao tng cua BCNTT. V vay, 3/4 so benh nhan viem cau than liem
the typ III, co them cac trieu chng cua cac benh ly viem mach mau he thong (th du viem
mach Wegener, viem a ong mach dang not...) do khang the ANCA co kha nang hoat hoa cac
BCNTT, lam ton thng te bao noi mo mach mau.

ai the: Than to, nht mau, tren be mat co cham xuat huyet.
- Vi the: Liem the c tao bi cac te bao bieu mo la ngoai bao Bowman tang sinh, cac
ai thc bao va mono bao; xen ke gia cac lp te bao cua liem the la cac dai fibrin. Co hnh
anh v mang ay khi khao sat di knh hien vi ien t.
Lien he lam sang: Benh nhan co tieu mau, am nieu trung bnh, co the co cao huyet ap
va phu. a so benh nhan co thieu nieu nang. Benh dien tien nhanh chong en suy than trong
vong vai tuan hoac vai thang, benh nhan can phai c loc than hoac thay than. Thay huyet
Benh ly Than 299
tng ch co ch oi vi cac benh nhan b hoi chng Goodpasture.
Hnh 16: Viem cau than liem the ()
BENH ONG THAN MO KE

I. VIEM ONG THAN MO KE
Viem xay ra au tien mo ke va ong than, sau o co the lan en cau than. Nguyen
nhan gay viem ong than - mo ke co the la vi khuan, thuoc, roi loan chuyen hoa (ha kali-mau),
tia xa va phan ng mien dch.
A. Viem than - be than cap (Acute pyelonephritis):
Viem cap tnh tao mu than va be than do vi khuan, hau nh luon i kem vi nhiem
khuan ng tieu di. Trieu chng xay ra ot ngot, benh nhan thay au vung that lng, sot, n
lanh, xet nghiem nc tieu thay co mu va vi khuan, co the kem theo cac trieu chng kch thch
bang quang - nieu ao nh tieu kho, tieu lat nhat, tieu gat. Benh thng co dien tien t gii han;
tr trng hp benh nhan co cac yeu to thuan li (nh tac nghen ng tieu, trao ngc bang
quang - nieu quan, co thai, at ong thong hoac ong soi ng nieu) lam benh de tai phat hoac
tr nen man tnh.
Nguyen nhan gay benh chu yeu la cac trc khuan gram am ng ruot, thng gap
nhat la Escherichia coli. Cac vi khuan khac nh Proteus, Klebsiella, Enterobacter va
Pseudomonas hay gay nhiem khuan ngc dong, nhat la nhng benh nhan c soi bang
quang hoac co at ong thong nieu ao.
Vi khuan en than bang:
- ng mau: thng th phat sau nhiem khuan huyet hoac viem noi tam mac nhiem
khuan
- Nhiem khuan ngc dong: thng gap nhat, n de mac benh hn nam do nieu ao
ngan.
Hnh thai ton thng:

- ai the: Be mat than noi len nhieu o ap xe nho, nam rai rac hoac khu tru tai mot vung
cua than, co the hoa nhap vi nhau tao thanh mot o mu duy nhat. Ton thng co the thay 1
hoac ca 2 than (hnh 17).
Benh ly Than 300
Hnh 17: Viem than-be than cap, be mat than noi nhieu o ap xe nho (mui ten) (A); Mo ke va ong than (1)
tham nhap BCNTT trong khi cau than van bnh thng (B), co cho tao ap xe (1) (C).
- Vi the: hnh anh viem cap tnh hoai t sinh mu va hnh thanh o ap xe mot hoac hai
nhu than. giai oan sm, nhiem khuan con gii han mo ke, sau o mi lan vao ong than.
Trong ong gop, cac bach cau a nhan trung tnh tao nen nhng tru bach cau ac trng, co the
tm thay khi lam xet nghiem nc tieu. Cau than va mach mau than con bnh thng khong b
ton thng. Trng hp nang, nhu than co the b hoai t.
B. Viem than - be than man (Chronic pyelonephritis):

La tnh trang viem kinh nien mo ke gay hoa seo nhu mo than lam bien dang he thong
ai - be than. Benh thng dien tien dan en suy than man mot cach am tham. Phan biet hai
loai: (Hnh 18)
Hnh 18: S o phan biet hnh anh ton thng cua 2 loai viem than- be than man
- Viem than be than man do tac nghen:

Tac nghen ng tieu tao ieu kien thuan li cho nhiem khuan tai phat nhieu lan, gay
x hoa va viem than be than man. Viem than - be than man co the ch xay ra mot ben than
trong trng hp tac nghen do soi, hoac cht hep bat thng mot nieu quan; hoac ca hai than
trong trng hp co d tat bam sinh nieu ao (van nieu ao sau,). Tac nghen lam tang ap lc
ngc dong, lam gian tat ca cac ai than, be than. Nhu mo than vung tuy va vo b nhiem khuan
tai i tai lai, lam nhu than b huy va hoa seo vo than ben tren.
Benh ly Than 301
- Viem than be than khong do tac nghen:
ai a so cac trng hp la do trao ngc bang quang nieu quan, xay ra mot ben
hoac ca hai ben than. Ap lc do trao ngc tac ong chu yeu len cac ai than vung cc, do
o than ch b hoa seo cac cc tren va di.

- ai the: Than b x hoa, vo than mong, tren be mat than co nhng seo lom rai rac
khap than oi vi loai viem than-be than do tac nghen, hoac khu tru tai cc than oi vi loai th
hai.
- Vi the: Ca 2 loai co hnh anh vi the giong nhau: mo ke tham nhap limpho bao, tng
bao va b x hoa. Ong than gian co the cha cac tru hyalin; cau than co the hoan toan khong b
anh hng hoac co x hoa quanh cau than. Thanh mach mau b x hoa hoac hyalin hoa. Mot so
trng hp cau than b x hoa tng o th phat.
Hnh 19 : Viem than- be than man do tac nghen, cac ai than gian, teo nhu than (A); Mo ke
tham nhap te bao viem man, ong than gian cha tru hyalin (B)
C. Viem than mo ke do thuoc

Mot so thuoc khang sinh va giam au co the gay viem than.
Phan biet hai loai:
1. Viem than - mo ke cap tnh do thuoc:
C che benh sinh: thuoc tac ong nh mot hapten, kch thch ap ng mien dch dch
the san xuat ra cac IgE (qua man typ I) va mien dch qua trung gian te bao (qua man typ IV)
chong lai te bao ong than va mang ay te bao ong than.
Cac trieu chng xuat hien khoang 2 tuan sau khi bat au dung thuoc gom sot, noi man
tren da, ure mau tang; trong nc tieu co hong cau, bach cau, tru bach cau. a so benh nhan
hoi phuc hoan toan sau khi ngng thuoc.
Hnh thai ton thng: mo ke phu ne, tham nhap te bao n nhan, chu yeu la limpho
bao va ai thc bao; cung co the thay nhieu bach cau a nhan ai toan va bach cau a nhan
trung tnh. oi vi 1 so loai thuoc nh Methicilline va thiazide, co the thay phan ng viem hat vi
u hat va ai bao trong mo ke. Cac cau than van bnh thng. (Hnh 20)
2. Benh than do thuoc giam au:

Thng gap phu n a s dung nhieu nam cac thuoc giam au nh phenacetin,
aspirin, acetaminophen, caffein, codein,
C che benh sinh: Nhu than b hoai t do thuoc trc tiep lam ton thng te bao; hoac
gian tiep do thuoc c che tac dung gian mach cua prostaglandin, gay ra thieu mau nhu than.
Benh ly Than 302
Benh nhan en v suy than man, cao huyet ap, thieu mau. Neu ngng thuoc, chc
nang than co the cai thien.
Hnh thai ton thng:
- ai the: Nhu than hoai t co mau vang nau, nhan nhum, troc ra va ri vao be than.
- Vi the: Nhu than hoai t ong, rai rac co cac o calci hoa nghch dng; mo ke viem,
x hoa; co hnh anh day mang ay cac mach mau nho.
Hnh 20: Viem than - mo ke cap tnh do thuoc, mo ke phu ne tham nhap te bao n nhan, bach cau ai toan
II. HOAI T ONG THAN CAP (Acute tubular necrosis):

Hoai t ong than cap la nguyen nhan gay suy than cap thng gap nhat. Hoai t ong
than cap co the do thieu mau hoac do oc chat. Hoai t ong than cap gay suy than cap theo
cac c che sau:
Dien tien lam sang gom 3 giai oan:

- Giai oan khi phat: keo dai khoang 36 gi, lng nc tieu giam nhe va ure mau
tang.
- Giai oan duy tr: trong giai oan nay, te bao ong than b ton thng, bong troc gay
nghen ong than, lng nc tieu giam xuong ch con 50-400 ml/ngay, thieu nieu keo dai trong
vai ngay co khi ti 3 tuan, benh nhan co the t vong trong giai oan nay neu khong c ieu tr
ho tr hoac tham phan kp thi.
- Giai oan hoi phuc: lng nc tieu tang do mat kha nang co ac nc tieu, co the at
ti 3 lt/ngay, keo dai trong vong vai ngay, chc nang ong than van cha hoi phuc, do o, trong
Benh ly Than 303
giai oan nay benh nhan de b mat can bang ien giai, de nhiem khuan nang va co the t
vong. Sau giai oan hoi phuc, lng nc tieu ve bnh thng nhng nhieu thang sau chc nang
ong than mi hoi phuc hoan toan.
A. Hoai t ong than cap do thieu mau (Ischemic acute tubular necrosis):
Benh nhan b soc do chan thng, bong, nhiem khuan, huyet ap tut lam giam ti mau vung
quanh ong than.
Hnh thai ton thng:
- ai the: Than sng to, vung vo nht nhat, vung tuy sung huyet.
- Vi the: Cau than va mach mau khong b ton thng. Ong than gan gian rong, lp bieu
mo b ep det, mat b ban chai. Rai rac tng te bao rieng le tren thanh ong than gan b hoai t,
ri vao long ong, e lo lp mang ay ben di. Long ong than xa va ong gop co cac tru nieu ai
toan (cau tao chu yeu bi protein Tamm-Horsfall, la 1 glycoprotein bnh thng van c che
tiet bi cac te bao cua nganh len cua quai Henle va ong than xa). Mo ke xung quanh phu va
tham nhap mot t te bao viem n nhan. (Hnh 21A)
Hnh 21: Hoai t ong than cap do thieu mau: Rai rac tng te bao ong than rieng le b hoai t bong ra (mui
ten), e lo mang ay (A); Hoai t ong than cap do oc chat, hoai t lan toa ong than gan (*) (B)
B. Hoai t ong than cap do oc chat (Toxic acute tubular necrosis) :

Cac oc chat co the gay hoai t ong than cap gom nhieu loai: Kim loai nang nh ch, thuy
ngan, thach tn (arsenic), vang, chrome, bismuth va uranium; dung moi hu c nh tetrachlorur
carbon, chloroform, dioxan, ethylene glycol; thuoc khang sinh ho aminoglycoside (nh
gentamycin, kanamycin; thuoc can quang;
Hnh thai ton thng:

- ai the: Than sng to, co mau o.
- Vi the: Hoai t te bao ong than lan toa hn so vi hoai t do thieu mau, chu yeu la cac
ong than gan v ay la phan ong nhay cam hn ca vi oc chat; ong than xa va ong thu thap t
b anh hng, mo ke tham nhap mot t te bao viem (hnh 21B).
BENH LY MACH MAU THAN

I. NHOI MAU THAN
Nguyen nhan: tac nghen cac nhanh chnh cua ong mach than do huyet khoi t buong tim
(nhoi mau c tim, rung nh keo dai), t van tim (viem noi tam mac nhiem khuan), do troc mang
x va t ong mach chu.
Lam sang: au lng hoac au bung d doi kem tieu mau.

Benh ly Than 304
Hnh thai ton thng:
- ai the: o nhoi mau trang hnh tam
giac, co ay ta tren be mat vo bao than.
(Hnh 22A)
- Vi the: vung hoai t ong gia, xung
quanh la mot vien xuat huyet.
O nhoi mau khi lanh se e lai mot
seo lom vo than. (Hnh 22B)
Hnh 22: o nhoi mau trang hnh tam giac (A);

Seo lom trang (*) do nhoi mau than (B).
II. X CNG THAN LANH TNH (Benign nephrosclerosis):

X cng than lanh tnh la thuat ng dung e ch cac ton thng than do cao huyet ap.
Ton thng than la hau qua cua tnh trang than thieu mau lau dai.

- ai the: Than hai ben giam kch
thc, be mat co nhieu hat mn giong hnh
anh da san. Vo than mong.
- Vi the: Khi au thanh cac tieu

ong mach b lang ong chat hyalin, day len
gay hep long mach lam thieu mau nuoi nhu
mo than. Giai oan sau, cac bui mach cau
than cung b tac nghen do lang ong chat
hyalin. Thieu mau nuoi than lam cac ong
than b teo, mo ke b x hoa va ngam mot t Hnh 23: Than teo, be mat co hat mn (A); hep long
te bao viem. tieu ong mach than do lang ong hyalin (B)
Lien he lam sang: ton thng x cng cau than lanh tnh hiem khi dan en suy than. Tuy
nhien chc nang than cung co the b anh hng: giam kha nang co ac nc tieu, hoac giam
o loc cau than, tieu am mc o nhe. Benh nhan thng t vong v cac bien chng tim hoac
tai bien mach mau nao do cao huyet ap, hn la do cac bien chng tai than.
III. X CNG THAN AC TNH (Malignant nephrosclerosis):

X cng than ac tnh la thuat ng dung e ch cac ton thng than benh nhan cao
huyet ap ac tnh. Cao huyet ap ac tnh la tnh trang huyet ap tam trng tang tren 130mmHg,
phu gai th, tang ap nao, suy than. Cao huyet ap ac tnh gap 5% cac trng hp cao huyet ap
hoac xay ra ot ngot tren benh nhan cha he b cao huyet ap trc o.

- ai the: kch thc than thay oi t, co the van bnh thng hoac ch hi nho i, tuy
theo thi gian b cao huyet ap trc o. Be mat vo than co cac cham xuat huyet lom om o.
- Vi the: cac tieu ong mach b lang ong chat dang fibrin va tham nhap te bao viem
cap tnh, gay hoai t thanh mach (viem tieu ong mach hoai t). Cac tieu ong mach ln hn
co hnh anh x hoa tieu ong mach tang san giong nh cu hanh. Co the co huyet khoi trong
long cau than hoac trong cac tieu ong mach b hoai t.
Benh ly Than 305
Hnh 23: Viem tieu ong mach hoai t, co lang ong chat dang fibrin va tham nhap te bao viem (A), x hoa
tieu ong mach tang san, giong cu hanh (B)
Lien he lam sang: Benh nhan thay nhc au, hoa mat, buon non va non, nhn m, co
am iem trc mat, tieu mau va tieu am, co the t vong do ure mau tang, xuat huyet nao hoac
suy tim.
SOI THAN
Soi than co the hnh thanh trong ong gop cua than hoac
cac ni khac trong ng nieu; tuy nhien v tr thng gap nhat la
ai- be than. Soi than xay ra nam nhieu hn n; kch thc
thay oi, t rat nho ( < 1mm) en rat ln (choan het ai be than).
Bien chng thng gap cua soi than la tieu mau, nhiem trung
tieu ngc dong, viem mu ai-be than, than nc, than mu.
Ve thanh phan hoa hoc cua soi, a so la soi oxalate calci va
phosphat calci, chiem 75% trng hp; phan con lai la soi urat,
soi struvit, soi cystin. (Hnh 24)
Neu a gay bien chng, can lay soi ra bang phau thuat
hoac sieu am tan soi
Hnh 24: Than nc do soi ln, choan het ai-be than
GHEP THAN
oi vi hau het benh nhan suy than giai oan cuoi th ghep than la mot chon la ieu tr
tot, nhng co kha nhieu kho khan can c giai quyet. Ngoai viec tm c ngi cho than phu
hp, con co hien tng mien dch thai ghep xay ra ngi nhan; than ghep co the b ton thng
do benh than goc hoac do thuoc c che mien dch. Sau ay la bang phan loai thai ghep va hnh
anh ton thng ac trng tren than ghep. (Hnh 25)
THAI GHEP ONG LOAI TON THNG AC TRNG
Thai ghep toi cap - the dch Hoai t xuat huyet lan toa, co BCNTT trong mao mach quanh ong than
Thai ghep cap - te bao
* Thai ghep cap ong than-mo ke Viem ong than (co bach cau n nhan trong ong than)
* Thai ghep cap te bao-mach mau Viem ao trong ong mach (co bach cau n nhan trong lp ao trong)
Benh ly Than 306
Thai ghep cap - the dch
* Thai ghep cap mao mach-the dch BCNTT va C4d trong mao mach cau than va mao mach quanh ong than
* Thai ghep cap mach mau-hoai t Hoai t ong mach dang fibrin
Thai ghep man Day ao trong ong mach, x hoa mo ke va teo ong than
Day thanh mao mach cau than
Co C4d trong mao mach cau than va mao mach quanh ong than
Hnh 25: Thai ghep cap the- dch, mien dch huynh quang cho thay co C4d trong mao mach cau than va mao
mach quanh ong than (A); ong mach trong than ghep b hoai t dang fibrin, thanh mach lang ong chat
dang fibrin (*) va tham nhap te bao viem (B).
U THAN
I. U LANH
U lanh cua than co kch thc nho, nen thng ch c phat hien khi lam t thiet hoac
khi phai mo cat than v mot ly do khac.
U m - c trn mach mau (Angiomyolipoma): trong a so cac trng hp, u khong gay trieu
chng lam sang, tr phi u b xuat huyet co the gay au. U nam trong nhu mo than, mau vang.
Cau tao vi the cua u gom mo m, mo c trn va cac mach mau co thanh day. U co moi lien he
vi benh x hoa cu (tuberous sclerosis), mot benh di truyen lam benh nhan co nhieu hamartom
hoac cac khoi u than, nao, tim, da va cac c quan khac.
II. U AC
A. Carcinom te bao ong than (Renal cell carcinoma):
Chiem 80-90% cac u ac cua than va 2% cac ung th ngi ln. Xuat o benh gii
nam cao gap oi gii n. Tuoi mac benh trung bnh la 60 tuoi.
Cac yeu to nguy c: Hut thuoc la, beo ph phu n, cao huyet ap, tiep xuc vi asbestos,
dau m, kim loai nang.
Lien he lam sang: Tam chng ac trng cua benh la tieu mau, au am vung that lng
va khoi u bung. Tren 50% benh nhan co trieu chng tieu mau. Tieu mau vi the lien tuc, thnh
thoang co nhng t tieu mau ai the thoang qua. Khi u u ln, co the gay au va s thay c
vung that lng. U san xuat ra erythropoietin gay chng a hong cau. Tien lng benh phu
thuoc vao mc o lan tran va tnh trang xam nhap mach mau cua u: 50% benh nhan song them
10 nam neu u ch khu tru than, t le nay giam xuong con mot na neu u a lan tran ra khoi
than.
Benh ly Than 307
Hnh thai ton thng:
- ai the: u co kch thc 3-15 cm, xuat phat t vo than. U tron, gii han ro, mat cat mau
vang, trung tam co vung xuat huyet, hoai t ong, tao nang.
- Vi the: te bao u sap xep thanh cac cau truc be, day, nhu, hoac thanh ong. Te bao
hnh vuong, gii han te bao ro, bao tng giau glycogen va lipid. Tuy theo lng lipid va
glycogen, te bao se co bao tng sang (te bao sang) hoac co hat (te bao hat). Mo em rat t
nhng giau mach mau. U co the xam lan ra khoi vo bao than, di can hach, di can xa en phoi
va xng. (Hnh 26)
Hnh 26 : ai the va vi the cua carcinom te bao than loai te bao sang
B. U Wilms (U nguyen bao than Nephroblastoma)

U Wilms la u ac thng gap tre em di 10 tuoi. 99% cac trng hp benh xuat hien
le te, khong co tnh gia nh. Ch mot so t trng hp c xac nh la co tnh di truyen theo
kieu gen troi - nhiem sac the thng (co lien quan en ot bien mat oan nhiem sac the 11).
Lien he lam sang: tre co khoi u to bung, oi khi kem theo trieu chng au bung, tac
ruot, tieu mau, cao huyet ap. U phat trien nhanh, nhieu trng hp a co di can phoi vao thi
iem chan oan. ieu tr phoi hp xa, hoa va phau co the cai thien tien lng benh. Tre nho
hn 2 tuoi co tien lng tot hn.

- ai the: u co kch thc ln, con gii han bi mot vien mong vo than va vo bao than,
hoac a xam lan qua vo bao than. Mat cat phong, mau nau nhat hoac trang xam.
Hnh 27 : U Wilms kch thc ln, mat cat nau nhat (A); vi the gom 3 thanh phan. mo mam trung
than (1), ong tuyen cha trng thanh (2) va mo em non (3) (B).
Benh ly Than 308
- Vi the: u cau tao bi 3 thanh phan:
+ Mo mam trung than: gom nhng te bao co kch thc nho, hnh bau duc, bao tng t,
sap xep thanh o hay thanh be.
+ Bieu mo cha trng thanh: gom cac te bao sap xep thanh cac cau truc ong nho, oi
khi tao thanh cac cau truc giong nh cau than.
+ Mo em cha trng thanh: nam xen lan vi cac thanh phan tren, gom cac te bao
hnh thoi khong biet hoa, oi khi cac te bao nay co the biet hoa thanh nguyen bao si, te bao c
van, xng, sun, m.
C. Carcinom nieu mac (te bao chuyen tiep) cua be than (Urothelial carcinoma):
Carcinom te bao chuyen tiep cua be than t gap, chiem 5-10% cac u than.
Nguyen nhan: carcinom te bao chuyen tiep co moi lien he vi tnh trang lam dung thuoc
giam au, tiep xuc vi thuoc nhuom aniline, cao su, nha,
Khoi u phat trien tao nhu trong he thong ai be than, gay trieu chng tieu mau va tac
nghen ng nieu.
- ai the: u dang choi sui tao nhu, mat o mem, co the choan het ai-be than, chen ep
tuy than.
- Vi the: bieu mo chuyen tiep tang sinh nhieu lp, tao nhu; nhan te bao tang sac, co
the d dang.
Hnh 28: ai the va vi the carcinom nieu mac dang choi sui trong be than, chen ep tuy than.
Benh ly Than 309
1. Hnh anh vien oi mang ay cau than khi nhuom bac gap trong :
A/ Viem cau than sang thng toi thieu B/ Viem cau than IgA
C/ Viem cau than mang D/ Viem cau than liem
E/ Viem cau than mang tang sinh
2. Ton thng vi the quan trong trong viem cau than tien trien nhanh la :
A/ Tang sinh gian mach B/ Mang ay cau than co hnh vien oi
C/ Mang ay cau than co gai D/ Lang ong hyalin quai mao mach
E/ Liem te bao
3. Mot benh nhan n 28 tuoi b viem hong do lien cau khuan, ieu tr bang ampicillin trong 7 ngay
th het sot va au hong; nhng sau 2 tuan lai thay sot tr lai, da noi man o va nga, nc tieu
co protein, hong cau va bach cau ai toan. Nhieu kha nang nhat benh nhan ang b bien chng:
A/ Viem cau than hau nhiem trung B/ Viem than-be than cap
C/ Hoai t ong than cap D/ Viem than-mo ke cap tnh do thuoc
E/ Viem cau than mang
4. Mot be trai 3 tuoi t 3 tuan nay thay met moi, phu toan than va khong kem sot, khong cao
huyet ap. Xet nghiem ure mau bnh thng, nc tieu khong co hong cau nhng cha nhieu am,
chu yeu la albumin. Loai ton thng than co nhieu kha nang nhat ang xay ra cho tre nay la:
A/ Viem cau than tang sinh te bao gian mao mach
B/ Viem cau than ton thng toi thieu
C/ Viem cau than man
D/ X hoa cau than tng o-cuc bo
E/ Benh cau than mang
5. Sang thng Kimmelsteil-Wilson la ton thng ac trng cua :

A/ X hoa cau than tng o - cuc bo B/ Viem cau than do lupus
C/ Benh than do tieu ng D/ Viem than do lupus ban o he thong
E/ Viem cau than man
6. Ton thng viem tieu ong mach hoai t va x hoa tieu ong mach tang san nh cu hanh
gap trong benh than nao sau ay :
A/ Viem than do lupus B/ Benh than do tieu ng
C/ X cng than lanh tnh D/ X cng than ac tnh
E/ Nghch san x c ong mach than
7. Viem than-be than cap:
A/ La tnh trang viem cap tnh hoa mu than va be than do vi khuan
B/ Vi khuan gay benh chu yeu la cac vi khuan sinh mu Gram dng
C/ Vi khuan en than chu yeu bang ng ngc dong t cac nhiem khuan ng
tieu di
8. Than hai ben giam kch thc, be mat co nhieu hat mn giong hnh anh da san; gap trong benh
than nao sau ay :
A/ Viem than do lupus B/ Ton thng than do cao huyet ap ac tnh
C/ Ton thng than do cao huyet ap D/ Benh than do tieu ng
E/ Nghch san x c ong mach than
Benh ly Than 310
9. U Wilms (u nguyen bao than)
A/ La u lanh B/ Thng gap ngi ln
C/ a so trng hp la do tiep xuc anilin D/ ieu tr ch can phau thuat cat u
E/ U gom 3 thanh phan : Mo mam trung than, bieu mo cha trng thanh va mo em
cha trng thanh
10. Carcinom te bao ong than:

A/ Bieu hien lam sang ac trng: tieu mau, au vung that lng va co khoi u bung
B/ a so u xuat phat t tuy than
C/ Te bao u thng co bao tng sang do cha nhieu glycogen va lipid
11. Soi than:

A/ V tr thng gap nhat la trong ai be than
B/ a so la soi oxalat calci va phosphat calci
C/ Gap gii n nhieu hn gii nam
D/ Ch A va B ung
E/ Ch A va C ung
12. Thai ghep cap - the dch:

A/ Co C4d mao mach cau than
B/ Gay viem ong than
C/ Gay viem noi mac ong mach
D/ Ch A va C ung
E/ Ch B va C ung
Benh ly hach limpho 311
BENH LY HACH LIMPHO
Muc tieu:
1. Mo ta va phan tch 3 loai viem hach.
2. Mo ta va phan tch 4 loai hach tang san phan ng.
3. nh ngha limphom Hodgkin cua hach. Mo ta cac typ mo hoc cua limphom Hodgkin.
4. nh ngha limphom khong Hodgkin (LKH) cua hach. Mo ta s o biet hoa cua cac te
bao limpho dong B va T va cac loai LKH tng ng. Neu cac loai LKH thng gap.
Neu ac iem giup phan biet limphom khong Hodgkin va hach tang san phan ng.
5. Mo ta cac ac iem cua ung th di can en hach.
i. CAU TRUC HACH LIMPHO

A. HE LIMPHO
- Cac c quan limpho trung ng gom tuy xng va tuyen c, la ni tao ra cac te bao
limpho B va limpho T trng thanh t cac te bao nguon cua tuy xng. Cac te bao limpho B va
T nay mang cac khang nguyen be mat ac hieu cho moi dong, co kha nang tao ap ng mien
dch khi tiep xuc vi khang nguyen cac c quan limpho ngoai vi.
- Cac c quan limpho ngoai vi gom lach, hach limpho va mo limpho niem mac (mucosa -
associated lymphoid tissue MALT), la ni hoat hoa, chuyen dang va tang san cua cac te bao B
va T, tao ra cac te bao thc hien (effector cells) va te bao nh (memory cells) tham gia vao cac
ap ng mien dch cua c the chong lai s xam nhap cua khang nguyen la.
B. CAU TRUC HACH LIMPHO
- Hach limpho nam doc tren ng i cua cac mach bach huyet. Hach co hnh bau duc,
ng knh doc t 2-20 mm, trung bnh la 15 mm. Hach thng tap trung lai thanh tng nhom,
nhan dong bach huyet dan lu ve t mot vung c the.
- Bao quanh hach la lp vo bao si. T mat trong vo bao tach ra cac vach mo lien ket si,
phan nhanh i sau vao trong nhu mo hach.
- Nhu mo hach co the c chia lam 3 vung: vung vo, vung can vo va vung tuy. (Hnh 1)
Hnh 1: S o cau truc hach limpho.

(1) Vung vo: cha cac nang limpho gom nhng nang limpho s cap va nhng nang limpho
th cap. ay la vung phan bo cua cac limpho bao B.
* Nang limpho s cap c tao thanh t nhng limpho bao B trng thanh nam trong mot
mang li tao bi cac te bao tua nang (follicular dendritic cells). Te bao tua nang, co nguon goc
t te bao nguon trung mo, co chc nang trnh dien khang nguyen cho cac limpho bao B.
* Nang limpho th cap cau tao bi mot vien limpho bao B nho (limpho bao B trng
thanh), con goi la vung vien, vay quanh mot trung tam mam sang. Trung tam mam c hnh
thanh khi co kch thch khang nguyen, la ni limpho bao B trai qua cac giai oan thay oi hnh
dang, phan chia te bao e cuoi cung tao ra c cac tng bao, san xuat khang the ac hieu co
ai lc cao oi vi khang nguyen la xam nhap (Hnh 2).
Hinh 2: A. Cau truc 1 nang limpho th cap gom trung tam mam vi 2 vung toi (1) va sang (2), c bao ben
ngoai bi vung vien (3). B. o phong ai ln, co the phan biet gia nguyen tam bao (1) va tam bao (2).
Co the tom tat qua trnh tang sinh va biet hoa cua cac limpho bao B khi co kch thch cua
khang nguyen nh sau (Hnh 3):
Khang nguyen la xam nhap vao c the, theo mach bach huyet en vao hach; cac khang
nguyen nay se c cac ai thc bao trong xoang bach huyet di vo va te bao tua nang bat
gi va trnh dien vi cac limpho bao B trng thanh (limpho bao B nho). ap ng mien dch
nguyen phat xay ra ngay sau khi cac limpho bao B nho nam trong vung vo hach gia cac nang
limpho, tiep xuc lan au tien vi khang nguyen. Cac limpho bao B nho chuyen dang thanh
nguyen bao mien dch B (immunoblast B) co kch thc ln, nhan tron, hach nhan rat ro nam
gia nhan, bao tng ai kiem; nguyen bao mien dch tang sinh, biet hoa thanh tng bao che
tiet khang the IgM; cac tng bao nay ch co i song ngan (khoang 3 ngay) va khang the tiet ra
cha co ai lc cao vi khang nguyen. giai oan muon cua ap ng mien dch nguyen phat
(khoang 3 en 7 ngay sau khi tiep xuc khang nguyen) va trong ap ng mien dch th phat,
limpho bao B nho a tiep xuc vi khang nguyen se di chuyen vao trong cac nang limpho s cap,
hoat ong tang sinh rat manh tao ra trung tam mam, bien nang limpho s cap thanh nang
limpho th cap.
Moi trung tam mam cha khoang 10.000 en 15.000 te bao B, c hnh thanh do s tang
sinh cua 3 en 10 limpho bao B nho, qua cac giai oan sau:
- Nguyen tam bao (centroblasts): la te bao ln nhan khong kha, co vai hach nhan nam
sat mang nhan va mot vien mong bao tng ai kiem, tap trung tai mot cc cua trung tam mam
tao thanh vung toi cua trung tam mam. Cac nguyen tam bao co kha nang tang sinh manh, trong
qua trnh tang sinh nay se dien ra hien tng tai to hp gen ma hoa vung C cua chuoi nang va
sieu ot bien than tai gen ma hoa vung V cua chuoi nang va chuoi nhe, nham chuyen oi lp
khang the be mat (t IgM sang IgG, IgA, IgE) va tang ai lc cua khang the oi vi khang
nguyen. Cac nguyen tam bao co ai lc kem oi vi khang nguyen la se b loai bo bang c che
t huy va c thu don bi cac ai thc bao. Cac nguyen tam bao co ai lc cao c gi lai,
biet hoa thanh cac tam bao (centrocytes).
- Tam bao co kch thc trung bnh, nhan co kha, hach nhan khong ro, bao tng t, tap
trung tai mot cc cua trung tam mam, tao thanh vung sang cua trung tam mam. Tam bao khong
con kha nang tang sinh, se biet hoa thanh tng bao che tiet khang the IgG, IgA hoac IgE co ai
lc cao vi khang nguyen. Cac tng bao nay co i song dai (co the suot i), se ri nang
limpho e vao trong cac day tuy hach; 10% so tng bao se ri hach, theo dong tuan hoan en
c tru trong tuy xng. Mot so tam bao khac se tr thanh te bao B nh nam tai vung ra ben
ngoai vung vien. Khi gap lai khang nguyen la lan th hai, te bao B nh nhanh chong chuyen
thanh tng bao, nh vay ap ng mien dch th phat bao gi cung nhanh va manh hn.
Hnh 3: S o cac giai oan biet hoa cua cac te bao limpho dong T va B.
(2) Vung can vo: nam ngay di cac nang limpho, cha limpho bao T nho (limpho bao
T trng thanh) nam trong mang li tao bi cac te bao tua chan xen ke va cac tnh mach sau
mao mach. Te bao tua chan xen ke (interdigitating dendritic cells) co nguon goc t te bao mam
cua tuy xng. Tnh mach sau mao mach co cau truc ac biet, c lot bi te bao noi mo cao va
la ni cac limpho bao ri he tuan hoan mau vao mo limpho. Sau khi tiep xuc vi khang nguyen
do te bao tua chan xen ke trnh dien, cac limpho bao T nho chuyen dang thanh nguyen bao
mien dch T (immunoblast T) co kch thc ln, nhan tron, hach nhan ro nam gia, bao tng ai
kiem, co the khong phan biet c vi nguyen bao mien dch B. Nguyen bao mien dch T co kha
nang tang sinh manh, tao ra nhieu te bao T thc hien (effector T cells) gom te bao T ho tr
CD4+ va T gay oc te bao CD8+; va cac te bao T nh (memory T cells).
(3) Vung tuy: cau tao bi cac day tuy cha cac limpho bao va tng bao, xen ke vi cac
xoang tuy.
- Bach huyet vao hach bang cac mach en xuyen qua vo bao hach, o vao xoang bach
huyet di vo en xoang quanh nang (nam trong vung vo) roi vao xoang tuy (nam trong vung
tuy). Trong cac xoang co nhieu mo bao (co kha nang thc bao). Xoang tuy hp vi xoang di
vo cua vung ron hach tao thanh mang li bach huyet dan dong bach huyet i ra khoi hach
bang mot mach i.
- ong mach cap mau cho hach i vao hach qua ron hach. ong mach phan nhanh nho
dan, theo cac vach mo lien ket, tao thanh cac mang li mao mach vung vo va vung can vo.
Mau sau o o vao cac tieu tnh mach, en tnh mach vung tuy va thoat ra ngoai qua ron hach.
C. KIEU HNH MIEN DCH (immunophenotype)
- moi giai oan phat trien va biet hoa, cac te bao mau (bao gom ca cac limpho bao)
bieu lo mot tap hp khang nguyen khac nhau. Tap hp khang nguyen nay c goi la kieu hnh
mien dch cua te bao mau. Nh vay ngi ta co the phan biet c te bao limpho ang giai
oan nao trong qua trnh phat trien, chuyen dang va biet hoa cua no da tren tap hp khang
nguyen ma no bieu lo, hay noi cach khac, da vao kieu hnh mien dch cua no. (Hnh 4)
Hnh 4: Kieu hnh mien dch cua cac limpho bao dong B va T nhng giai oan phat trien, chuyen dang va
biet hoa khac nhau. (TdT: terminal deoxynucleotidyl transferase; TCR: T cell receptor; DR: khang nguyen
phc hp chu yeu hoa hp mo lp II; sIg: surface immunoglobilin, khang the be mat).
- e xac nh kieu hnh mien dch, ngi ta s dung cac khang the ac hieu nhan dien
khang nguyen co tren be mat hoac trong bao tng cua cac te bao limpho. Co tren 1000 khang
the c san xuat ra t nhieu phong th nghiem khac nhau va co nhieu khang the khac nhau
cung nhan dien mot khang nguyen; do o, e co the thong hieu nhau de dang, ngi ta a a
ra mot he thong danh phap chuan hoa quoc te, c goi la cac CD (Cluster Designation Nhom
nh danh). Co nhieu CD khac nhau, moi CD c anh so va moi CD la mot nhom cac khang
the khac nhau cung nhan dien mot khang nguyen. Th du: CD20 la nhom gom cac khang the
khac nhau nh Leu-16, B1 cung nhan dien mot khang nguyen nam tren te bao limpho B; CD3 la
nhom gom cac khang the Leu-4, OKT3, T3 cung nhan dien mot khang nguyen nam tren te bao
limpho T.
- Trong qua trnh tang sinh va biet hoa, cac limpho bao co kieu hnh mien dch thay oi.
Th du: nguyen bao limpho B la mot tien than cua limpho bao B, co c quan limpho trung ng
va co kieu hnh mien dch CD34, TdT, HLA-DR, CD10, CD19, CD20, CD22, CD45, CD79a. Khi
biet hoa thanh limpho bao B trng thanh thanh thuc mien dch, no se mang kieu hnh mien dch
khac: mat bieu hien TdT, CD10 va CD34, bieu hien khang the be mat IgM va IgD, CD19, CD20,
CD22, CD79a, CD5. Khi chuyen dang thanh nguyen tam bao, kieu hnh mien dch tiep tuc thay
oi: khang the be mat IgM va IgD c chuyen lp thanh IgG, IgA hoac IgE, them bieu hien cua
protein bcl-6, CD79a. Khi thanh tng bao th them bieu hien CD138, mat bieu hien khang the
be mat nhng che tiet c khang the IgG, IgA hoac IgE.
- Hai phng phap chnh thng c dung e xac nh kieu hnh mien dch cua te bao
dong limpho: Hoa mo mien dch (Immunohistochemistry) va o te bao dong chay (Flow
cytometry). Hai ky thuat nay ho tr nhau giup chan oan benh ly cua cac te bao mo tao huyet.
II. CHC NANG HACH LIMPHO

Hach co hai chc nang quan trong, lien he chat che vi nhau:
- Loc dch bach huyet, thc bao cac vi trung va vat la, v.v.
- Mien dch: cac phan t tren cung ong thi la cac khang nguyen la co kha nang kch
thch tao ap ng mien dch. Tuy theo loai ap ng mien dch (mien dch dch the hoac mien
dch qua trung gian te bao) ma cac vung hach lien quan se co nhng thay oi.
III. VIEM HACH

Viem hach c phan thanh 3 loai (Hnh 5): viem hach cap tnh, viem hach man tnh va
viem hat.
Tac nhan gay benh co the la cac vi sinh vat nh virut, vi trung, nam, ky sinh trung
Hnh 5: S o viem hach.

A. VIEM HACH CAP TNH
- Lam sang: hach sng to va au. Trng hp nang, nhu mo hach b hoai t, hnh thanh
cac o ap xe ln, hach tr nen phap pheu. Da tren hach viem o va co the do mu trong trng
hp nhiem trung lan tran en da va mo di da.
- ai the: hach to mem, mat cat hach phong, o xam, sung huyet.
- Vi the: giai oan sm, cac xoang bach huyet dan rong do tang lu lng bach huyet
en hach. Cac mach mau dan rong, vo bao hach b phu, trung tam mam tang san tao ra nhng
nang limpho th cap vi nhieu hnh anh phan bao, bach cau a nhan trung tnh xam nhap vao
tam mam va cac xoang bach huyet. Neu nhiem trung nang, nhu mo hach hoai t va tao thanh o
ap xe cha nhieu bach cau a nhan thoai hoa.
Sau ieu tr nhiem trung, hach co the tr lai cau truc bnh thng hoac b x hoa neu cau
truc hach a b pha huy qua nhieu.
B. VIEM HACH MAN TNH
- Khi mot hach viem cap tnh khong c ieu tr ay u hoac viem hach tai i tai lai nhieu
lan, hach viem tr thanh man tnh.
- ai the: hach viem man tnh co the sng to, khong au, mat o dai va chac; hoac b x
hoa teo nho lai.
- Vi the: Vung vo hach, cac nang limpho tang hoat ong, trung tam mam dan rong. Trong
vung can vo co tang san cac te bao limpho va cac tnh mach sau mao mach. Vung tuy hach co
nhieu tng bao va limpho bao. Vo bao hach va cac vach x thng day, tham nhap nhieu
limpho bao.
C. VIEM HAT
- Co the do nhieu tac nhan khac nhau: nhiem trung (vi trung lao), nhiem nam, phan ng
vi d vat, benh sarcoidosis, v.v.
- Hnh anh mo hoc ac trng la s hien dien cua cac u hat trong nhu mo hach. U hat la
nhng not c tao bi cac te bao dang bieu mo va ai bao nhieu nhan, bao quanh bi mot
vien te bao limpho. Kch thc u hat khoang 1-2mm ng knh.
- Mot tac nhan gay viem hat thng gap la vi khuan lao (mycobacterium tuberculosis).
Hach sng to, 1 phan hay toan bo nhu mo hach b xam chiem bi cac nang lao. Nang lao c
tao thanh t mot hay nhieu u hat lao, cau tao bi cac te bao dang bieu mo, ai bao Langhans,
tng bao, limpho bao, trung tam co hoai t ba au (xem hnh 27, chng viem va sa cha).
IV. HACH TANG SAN PHAN NG

Hach tang kch thc do tang san mot hoac nhieu thanh phan te bao cua hach, phan ng
lai vi cac kch thch khang nguyen. ay la mot ton thng lanh tnh va co tnh kha hoi (Hnh 6).
Rat nhieu tac nhan kch thch hach tang san phan ng (vi trung, virut, hoa chat, moi trng o
nhiem, thuoc, v.v.). Hach sng to (thng < 1,5cm), mat o mem hoac chac, gii han ro, di
ong.
Tuy khang nguyen co kha nang kch thch gay ap ng mien dch dch the hay mien dch
qua trung gian te bao, hnh anh tang san cua hach se khac nhau. Co 4 hnh thai mo hoc chnh:
Hnh 6: S o cac hnh thai tang san phan ng lanh tnh cua hach.
A. TANG SAN NANG

- Tang san nang thng gap trong cac nhiem trung man tnh do cac tac nhan kch thch
gay ap ng mien dch dch the. Mot so nguyen nhan co the ke en gom: viem khp dang thap,
giai oan sm cua nhiem HIV (human immunodeficiency virus), viem amian, nhiem
toxoplasma, v.v.
- Vi the: cac trung tam mam tang san, gian rong, cha cac te bao limpho B nhng giai
oan biet hoa khac nhau. Vung quanh nang tham nhap tng bao, nguyen bao mien dch.
Can phan biet hnh anh tang san nang vi hnh anh nang cua limphom khong Hodgkin
dang nang. Nang limpho tang san: (1) hach van bao ton cau truc bnh thng; (2) cac nang
limpho co kch thc va hnh dang rat khac nhau; (3) trung tam mam phan cc ro, a dang te
bao, nhieu ai thc bao va phan bao; (4) vien quanh tam mam la cac te bao limpho bnh
thng. (Hnh 7)
Hnh 7: Hach tang san nang, cac nang limpho kch thc va hnh dang khong eu (A); Trung tam mam a
dang te bao, nhieu ai thc bao va phan bao (B).
B. TANG SAN VUNG CAN VO

- Tang san vung can vo thng gap trong nhiem virut, sau chch nga benh au mua,
hoac do phan ng vi mot so thuoc.
- Vi the: te bao T tang sinh va biet hoa thanh cac nguyen bao mien dch. Tang san lan
rong vung can vo oi khi xoa mat cac trung tam mam, thay vao o la rat nhieu cac te bao
limpho, nguyen bao mien dch T. Cac tnh mach sau mao mach cung co the tang so lng.
(Hnh 8)
Hnh 8: Hach tang san vung can vo, vung can vo tang san, xoa gan het cac trung tam mam (A); Tang san
cac tnh mach sau mao mach (B).
C. TANG SAN XOANG

- Tang san xoang thng gap cac hach dan lu t cac khoi ung th.
- Vi the: Cac xoang dan rong, chen ep phan nhu mo con lai. Trong xoang cha ay dch
va cac mo bao tang sinh manh. Vung tuy hach ln rong ra do cha nhieu mo bao. Cac te bao
nay co the xep thanh am ac. (Hnh 9)
Hnh 9: Hach tang san xoang, cac xoang dan rong, cha ay mo bao tang san (mui ten).
D. TANG SAN HON HP

- Tang san hon hp khi co hnh anh phoi hp cua 3 loai tang san tren. Tac nhan gay benh
kch thch hach tang san cac nang limpho, trung tam mam dan rong, kem theo hien tng tang
sinh cac nguyen bao mien dch va cac te bao limpho trong mo limpho chen gia cac nang, oi
khi co hien tng tang san xoang vi cac xoang dan rong cha ay mo bao. Co the gap tang
san hon hp trong cac benh nh tang bach cau n nhan nhiem khuan, nhiem toxoplasma,
benh meo cao.
V. UNG TH NGUYEN PHAT CUA HACH

Ung th nguyen phat cua hach hay limphom (lymphoma) la benh ly tan sinh ac tnh cua cac
te bao xuat nguon t mo limpho, bieu hien di dang cac khoi u ac.
Limphom c chia thanh hai nhom chnh: Limphom Hodgkin va Limphom khong
Hodgkin. Tuy eu xuat phat t mo limpho nhng limphom Hodgkin va Limphom khong Hodgkin
co cac ac iem ve lam sang va giai phau benh khac nhau.
A. LIMPHOM HODGKIN
Limphom Hodgkin la benh ly tan sinh ac tnh cua hach, ac trng bi s hien dien cua te
bao Reed - Sternberg nam tren nen cac te bao viem phan ng, vi tnh trang x hoa nhng
mc o khac nhau.
1. Dch te hoc va c che benh sinh
Benh chiem t le 30% cac trng hp limphom. Gii nam mac benh hi nhieu hn gii n,
t le nam/ n la 1,4/ 1. Benh thng xay ra hai nh tuoi: 15-20 tuoi va sau 50 tuoi. Tai cac
nc ang phat trien, tan suat benh cao tre em.
C che benh sinh khong ro, nhng co nhieu bang chng cho thay co moi lien quan gia
Limphom Hodgkin va tien s nhiem virut Epstein - Barr (EBV). T le benh tang cao gap 2-3 lan
nhng benh nhan b benh tang bach cau n nhan nhiem khuan (benh do nhiem EBV, bieu hien
lam sang gom cac trieu chng sot, au hong, hach to).
2. Bieu hien lam sang va xep giai oan lam sang
Trieu chng khi au luon la tnh trang sng to cua mot hach hoac mot nhom hach, phan
bo doc theo truc c the, thng thay nhat la vung co va trung that (hn 50% cac trng hp);
benh se lan tran sang cac hach cua vung lan can theo ng bach huyet; va khi benh a tien
xa, theo ng mau en lach, gan va tuy xng. Rat hiem khi benh Hodgkin lai khi phat vi
trieu chng ngoai hach. Khoang 25% cac trng hp co trieu chng c nang gom: sot, o mo
hoi em, sut can (tren 10% trong lng c the trong vong 6 thang); ac biet khi benh tien trien
se co them trieu chng nga da.
He thong xep giai oan lam sang cua Ann Arbor (bao gom hoi benh s, kham lam sang
ket hp vi cac phng phap can lam sang khac nh chup mach limpho, X quang long ngc,
sinh thiet gan, tuy xng, chup X-quang cat lp ien toan) c s dung e anh gia mc o
lan tran cua benh, la chon ieu tr va tien lng benh. Nhn chung, benh limphom Hodgkin co
tien lng tot, co the cha khoi trong hn 85% cac trng hp vi lieu phap xa tr va hoa tr.
Bang 1: He thong xep giai oan lam sang cua Ann Arbor (Dung chung cho limphom Hodgkin
va limphom khong Hodgkin).
Giai oan I: Ton thng mot vung hach duy nhat (I) hoac mot c quan hay v tr ngoai hach duy
nhat (IE).
Giai oan II: Ton thng hai vung hach tr len cung mot ben c hoanh (II) hoac ton thng khu tru
mot c quan hoac v tr ngoai hach (IIE).
Giai oan III: Ton thng cac vung hach hai ben c hoanh (III), khong kem (III) hoac kem vi (IIIE)
ton thng khu tru mot c quan hoac v tr ngoai hach
Giai oan IV: Ton thng lan tran mot hoac nhieu c quan hay v tr ngoai hach, co hoac khong co
ton thng hach.
Tat ca cac giai oan eu c chia thanh A (khong co) hoac B (co cac trieu chng sot, o mo hoi em, va/hoac sut can
tren 10% trong lng c the).
- ai the: hach thng to, oi khi rat to, tr trng hp benh c phat hien rat sm. Hnh
anh ai the tuy thuoc vao typ mo hoc. Mat o chac hoac cng tuy mc o x hoa. Mat cat ac,
co dang not; oi khi khong ong nhat do co cha cac o hoai t. Khi benh tien trien xa, nhieu
hach to lan can co the ket dnh lai thanh khoi ln. (Hnh 10)
- Vi the:
Nh nhng tien bo ln lao trong nghien cu ve
sinh hoc va lam sang trong 20 nam gan ay, phan
loai limphom Hodgkin a co thay oi. Ngay nay,
limphom Hodgkin c chia thanh hai thc the
benh, theo phan loai cua WHO (2008) la :
- Limphom Hogkin loai giau limpho bao dang cuc

- Limphom Hodgkin kinh ien, gom 4 typ mo hoc:
+ Limphom Hodgkin kinh ien loai x cuc
+ Limphom Hodgkin kinh ien loai hon hp Hnh 10: Limphom Hodgkin cua hach. Mat cat
te bao hach b x hoa va co nhieu not.
+ Limphom Hodgkin kinh ien loai giau limpho bao
+ Limphom Hodgkin kinh ien loai ngheo limpho bao
Hai thc the tren cua limphom Hodgkin co chung nhng ac iem ac trng a neu trong
nh ngha. Tuy nhien, chung co nhng khac biet ve ac iem lam sang va dien tien benh, ve
hnh thai va kieu hnh mien dch cua te bao u (te bao Reed - Sternberg) va ve thanh phan te bao
phan ng.
a. Limphom Hodgkin loai giau limpho bao dang cuc (nodular lymphocyte predominant
Hodgkin lymphoma):
Chiem 5% cac limphom Hodgkin. Thng gap benh nhan nam, tuoi 30-50. Ton thng
thng gap hach co, nach, ben, hiem khi trung that, lach hoac tuy xng. a so giai oan
I va II. Benh tien trien cham, oi khi co the t thuyen giam. Benh ap ng tot vi ieu tr va hiem
khi gay t vong.
Hnh anh vi the ac trng la:
- Cau truc hach b thay the mot phan hoac hoan toan bi cac cuc.
- Cuc gom chu yeu la cac limpho bao nho, mo bao va cac te bao LP (lymphocyte
predominant cells) nam rai rac. Te bao LP trc ay c goi la te bao L&H (lymphocytic and/or
histiocytic cell), la thanh phan tan sinh ac tnh ac trng cua limphom Hodgkin giau limpho bao
dang cuc. Te bao LP co kch thc ln, nhan ln co nhieu thuy giong hnh anh hat bap rang,
mang nhan mong, co nhieu hach nhan ai kiem. Mo bao va tng bao nam ra cua cuc. (Hnh
11)
Kieu hnh mien dch va nguon goc te bao bu: te bao LP co CD20+, CD79a+, bcl6+ va CD45+; J
chain +/-, Ig+/-, EMA +/-; CD15 -, CD30 -. Nguon goc te bao u co the la nguyen tam bao cua tam mam.
Hnh 11: Limphom Hodgkin loai giau limpho bao dang cuc, cau truc cua hach b thay the bi cac cuc (A);
Cuc gom cac te bao LP (mui ten), limpho bao nho, mo bao (B).
b. Limphom Hodgkin kinh ien (classical Hodgkin lymphoma):

Chiem 95% cac trng hp limphom Hodgkin. Da tren ac iem cua thanh phan te bao
phan ng va hnh thai te bao Reed - Sternberg (R-S), ngi ta chia limphom Hodgkin kinh ien
thanh 4 typ: Limphom Hodgkin kinh ien loai giau limpho bao, Limphom Hodgkin kinh ien loai
x cuc, Limphom Hodgkin kinh ien loai hon hp te bao, Limphom Hodgkin kinh ien loai ngheo
limpho bao.
b.1. Te bao R-S kinh ien la tieu chuan can thiet cho chan oan cac limphom Hodgkin
kinh ien. Te bao R-S kinh ien co kch thc ln (20-50m), bao tng nhieu bat mau ai toan
nhe va co t nhat 2 thuy nhan hoac 2 nhan. Nhan sang, mang nhan day, chat nhiem sac tho
nam rai rac nhng cha lai mot khoang sang quanh hach nhan. Hach nhan ln, tron, ai toan,
nam chnh gia nhan. Hnh anh ien hnh nhat la te bao R-S kinh ien co 2 nhan hoac 2 thuy
nhan nam oi xng nhau, giong nh mat cu (Hnh 12). Trng hp te bao R-S kinh ien co
nhieu thuy nhan co the trong giong te bao LP; phan biet da vao hach nhan, hach nhan cua te
bao R-S th to hn va ai toan. (Hnh 13)
Hnh 12: Te bao Reed-Sternberg kinh ien ien hnh co nhan hai thuy, hach nhan o, ro, oi xng nhau nh
hnh mat cu, nhuom HE (A), lat cat ban sieu mong, nhuom xanh toluidin (B), lat cat sieu mong,
chup di knh hien vi ien t (C), Nhuom hoa mo mien dch, dng tnh vi CD15 (D) va CD30 (E).
b.2. Cac dang bien the cua te bao R-S (Hnh 13)
Te bao R-S mot nhan (te bao Hodgkin) co hnh thai giong nh te bao R-S kinh ien, nhng
ch co mot nhan do nhan khong phan thuy. Te bao Hodgkin co trong tat ca cac typ cua limphom
Hodgkin kinh ien.
Te bao R-S dang hoc (lacunar cell): te bao ln (40-50m), bao tng nhieu va sang, nhan
nhieu thuy, hach nhan nho. Do co nh bang formol, bao tng b co lai, tao hnh anh te bao
nam trong mot hoc sang. Te bao R-S dang hoc gap nhieu trong limphom Hodgkin kinh ien loai
x cuc.
Te bao R-S dang thoai san: te bao ln; nhan tang sac, a thuy rat d dang; hach nhan to.
Thanh phan te bao R-S va cac bien the chiem khong qua 10% the tch u.
Hnh 13: Cac bien the cua te bao Reed - Sternberg (RS): Te bao Hodgkin (mui ten) (A), Te bao R-S dang
nhieu thuy nhan giong te bao LP (B), Te bao R-S dang hoc (C) Te bao R-S dang thoai san (D).
Kieu hnh mien dch va nguon goc te bao u: te bao Reed - Sternberg co CD15+, CD30+. CD45-, J
chain -, CD20+/-, CD79a+/-. 98% trng hp limphom Hodgkin kinh ien, te bao u co nguon goc t te bao B
cua tam mam, mot so t con lai co nguon goc t limpho bao T ngoai vi.
b.3. Cac thanh phan te bao phan ng chiem hn 90% the tch u, gom limpho bao, tng
bao, bach cau a nhan ai toan, bach cau a nhan trung tnh va mo bao. T le thanh phan limpho
bao bnh thng so vi thanh phan te bao tan sinh cho biet mc o ap ng mien dch cua benh
nhan. Do o, typ mo hoc co so lng limpho bao thap chng to benh nhan ap ng mien dch
kem, tien lng benh se xau hn so vi typ mo hoc co t le te bao limpho cao.
b.4. Cac typ mo hoc:
Bang 2: Cac typ mo hoc cua limphom Hodgkin kinh ien. (Hnh 14,15)
Limphom Hodgkin Limphom Hodgkin Limphom Hodgkin Limphom Hodgkin
kinh ien loai giau kinh ien loai x kinh ien loai hon kinh ien loai
limpho bao cuc hp te bao ngheo limpho bao
T le % 5% 70% 20-25% < 5%
Gii Thng gap gii Nam/N = 1/1 Thng gap gii Thng gap gii
nam nam nam
Tuoi trung Hi cao hn cac typ 28 tuoi 37 tuoi 37 tuoi
bnh con lai
Giai oan I hoac II II III hoac IV IV
lam sang
Trieu chng t gap 40% cac trng Thng gap 80% cac trng
toan than hp hp
Vi the - Te bao R-S kinh - Cac dai si - Hnh anh hon hp Hnh anh ngheo
ien rat t, mot so collagen phan cat te bao vi nhieu te limpho bao va
co the trong giong nhu mo hach thanh bao R-S kinh ien, nhieu te bao R-S.
te bao LP nhng co cac cuc. nhieu te bao Co hai dang:
hach nhan ln hn - Trong cuc co te Hodgkin, nhieu - Dang x hoa lan
va ai toan. bao R-S dang hoc, bach cau a nhan toa: mo hach
- Nhieu limpho bao te bao R-S kinh trung tnh, bach cau ngheo te bao va b
trng thanh va mo ien t gap, nhieu a nhan ai toan, mo x hoa.
bao, bach cau a limpho bao, bach bao, tng bao, - Dang li: co
nhan khong co cau a nhan ai toan limpho bao. nhieu te bao RS
hoac rat t. va bach cau a - Hau nh khong co thoai san d dang,
- Khong co x hoa. nhan trung tnh. x hoa ai thc bao va
bach cau a nhan.
Tien lng Tot hn cac typ con Tot hn typ hon Xau hn typ x cuc Xau
lai hp te bao va va tot hn typ
ngheo limpho bao ngheo limpho bao
Hnh 14: Limphom Hodgkin kinh ien loai giau limpho bao: Cau truc hach b xoa (A); Te bao RS dang nhieu
thuy nhan giong te bao LP, nam tren nen rat nhieu limpho bao trng thanh va mo bao (B).
Hnh 15: Limphom Hodgkin kinh ien loai x cuc, mo hach b x hoa va co nhieu cuc (A) vi cac te bao R-S
dang hoc nam tren nen cac limpho bao va bach cau a nhan (B). Limphom Hodgkin kinh ien loai hon hp
te bao. Te bao R-S kinh ien, te bao Hodgkin nam tren nen nhieu limpho bao, mo bao, tng bao, BCN ai
toan, BCN trung tnh (C). Limphom Hodgkin kinh ien loai ngheo limpho bao. Nhieu te bao R-S dang thoai
san, rat t limpho bao (D)
ieu tr bang hoa tr va xa tr, a so cac trng hp limphom Hodgkin khoi benh. Ngay
nay, khi a co nhng lieu phap ieu tr hien ai, giai oan lam sang va trieu chng toan than tr
thanh nhng yeu to quan trong hn han trong tien lng benh.
B. LIMPHOM KHONG HODGKIN

Limphom khong Hodgkin (LKH) xuat phat t mot te bao chuyen dang ac tnh thuoc bat c giai
oan nao trong qua trnh tang sinh va biet hoa cua cac te bao dong B hay T. (Hnh 16)
1. Dch te hoc va c che benh sinh

Tan suat mac benh LKH thay oi tuy tng vung tren the gii, cao nhat My, chau Au va
Uc, thap nhat chau A. So trng hp mac benh hang nam co khuynh hng ngay cang gia
tang. Benh thng gap gii nam nhieu hn gii n. Tuoi mac benh trung bnh noi chung
khoang 60-70 tuoi, mot so loai LKH co tuoi mac benh trung bnh thap hn (th du: khoang 30
tuoi oi vi cac limphom Burkitt).
a so cac trng hp khong biet c c che benh sinh. Tuy nhien LKH co the co lien
quan vi mot so yeu to nh benh di truyen, tac nhan moi trng, tac nhan nhiem khuan. Mot so
gia nh co nhieu ngi cung mac LKH co the la do yeu to di truyen thc s hoac ch do cung
chung mot moi trng song. Tien s nhiem virus Epstein - Barr (EBV) gap trong 95% cac trng
hp Burkitt dch vung chau Phi va 15% cac trng hp Burkitt le te. 90% cac trng hp LKH
te bao T co tien s nhiem HTLV-1 (Human T-cell leukemia/lymphoma virus). Tnh trang suy
giam mien dch bam sinh hay mac phai, tiep xuc vi mot so hoa chat hoac che o an nhieu tht
va m cung lam gia tang nguy c mac benh LKH.
2. Bieu hien lam sang
Khac vi limphom Hodgkin, ch co 2/3 benh nhan LKH co trieu chng khi phat vi hach
sng to va khong au cac vung ngoai vi nh co, ben, nach hoac khuyu tay va rat kho d oan
c nhom hach tiep theo se b benh lan tran; 1/3 so benh nhan con lai khi benh vi trieu
chng limphom ngoai hach nh da, da day, nao bo. He thong Ann Arbor cung c s dung
e xep giai oan lam sang, tuy nhien tien lng cua benh nhan lai phu thuoc nhieu hn vao o
ac tnh cua tng the loai LKH. Cac loai co o ac thap nh limphom nang, limphom te bao B
vung vien, limphom limpho bao B nho benh nhan co the khong co trieu chng, dien tien benh
rat cham va co khi khong can ieu tr; trai lai, nhng loai co o ac cao nh limphom lan toa loai
te bao B ln, limphom loai thoai san, benh dien tien nhanh, lan tran khap c the va co the gay t
vong neu khong c ieu tr kp thi.
Hnh 16: Cac loai LKH tng ng vi cac giai oan biet hoa cua cac te bao limpho dong T va B

a. ai the: hach to, chac, mat cat ac trn lang nh tht ca.
b. Vi the: cac te bao limpho tan sinh ac tnh co hai kieu sap xep: (1) cac te bao tap trung
lai thanh tng am giong nang limpho, c goi la LKH dang nang; (2) hoac cac te bao lan tran
khap ni trong hach, c goi la LKH dang lan toa. (Hnh 17)
Hnh 17: Limphom khong Hodgkin, Hach to, dnh chum, mat cat lang mau trang xam (A); Cac te bao limpho
tan sinh ac tnh co hai kieu sap xep: dang nang (B) va dang lan toa (C).
ngi ln LKH dang nang chiem 40%, dien tien dan thanh dang lan toa. 60% co dang
lan toa ngay t au. tre em ch co dang lan toa va thng co o ac tnh cao.
Da tren cac ac iem ve nguon goc, hnh dang te bao, kieu hnh mien dch cua te bao,
cach sap xep thanh dang nang hay dang lan toa, kieu ot bien gen va ot bien nhiem sac the,
dien tien lam sang va tien lng, a co nhieu he thong phan loai limphom khac nhau. Tuy
nhien, bang phan loai ang c ap dung rong rai tren toan the gii hien nay la cua To chc Y
te the gii (WHO), vi phien ban cap nhat gan ay nhat la vao nam 2008. Bang phan loai u
limpho cua WHO bao gom hn 80 thc the khac nhau, phan vao 4 nhom ln cua LKH, nh trong
bang 3.
Bang 3: Phan loai cac LKH cua WHO (2008) (bang rut gon)
I. Cac u te bao tien B (Precursor B-cell neoplasms)

Benh bach cau cap/Limphom nguyen bao limpho (B-cell acute lymphoblastic leukemia/lymphoma (B-ALL))
II. Cac u te bao B ngoai vi (Peripheral B-cell neoplasms)
Benh bach cau man te bao limpho/limphom limpho bao nho (B-cell chronic lymphocytic leukemia/ /small lymphocytic lymphoma)
Benh bach cau tien limpho bao B (B-cell prolymphocytic leukemia)
Limphom limpho tng bao (Lymphoplasmacytic lymphoma)
Limphom vung ra lach va hach (Splenic and nodal marginal zone lymphoma)
Limphom vung ra ngoai hach (Extranodal marginal zone lymphoma)
Limphom te bao vung vien (Mantle cell lymphoma)
Limphom nang (Follicular lymphoma)
Limphom vung ra (Marginal zone lymphoma)
Benh bach cau te bao toc (Hairy cell leukemia)
U tng bao/U tuy tng bao (Plasmacytoma/plasma cell myeloma)
Limphom lan toa loai te bao B ln (Diffuse large B-cell lymphoma)
Limphom Burkitt (Burkitt lymphoma)
III. Cac u te bao tien T (Precursor T-cell neoplasms)
Benh bach cau cap/Limphom nguyen bao limpho T (T-cell acute lymphoblastic leukemia/lymphoma (T-ALL))
IV. Cac u te bao T va te bao NK ngoai vi (Peripheral T-cell and NK-cell neoplasms)
Benh bach cau tien limpho bao T (T-cell prolymphocytic leukemia)
Benh bach cau limpho bao hat ln (Large granular lymphocytic leukemia)
Mycosis fungoides/Hoi chng Sezary
Limphom te bao T ngoai vi, loai khong ac hieu (Peripheral T-cell lymphoma, not otherwise specified)
Limphom te bao ln loai thoai san (Anaplastic large cell lymphoma)
Limphom te bao T loai nguyen bao mien dch-mach mau (Angioimmunoblastic T-cell lymphoma)
Limphom te bao T lien quan vi benh ruot (Enteropathy-associated T-cell lymphoma)
Limphom te bao T giong viem mo m di da (Panniculitis-like T-cell lymphoma)
Limphom te bao T gan-lach (Hepatoplenic T-cell lymphoma)
Benh bach cau/Limphom te bao T ngi ln (Adult T-cell leukemia/lymphoma)
Limphom te bao NK/T ngoai hach (Extranodal NK/T-cell lymphoma)
Benh bach cau te bao NK (NK-cell leukemia)
Tan suat cac loai LKH thng gap c liet ke trong bang 4. ngi ln, thng gap nhat
la limphom lan toa loai te bao B ln va limphom nang; tre em thng gap cac loai limphom
dien tien nhanh nh limphom nguyen bao limpho, limphom Burkitt va limphom te bao ln (bao
gom dang thoai san va dang lan toa te bao B ln).
Bang 4: Tan suat cac LKH te bao B va te bao T/NK thng gap
Chan oan T le %
Limphom lan toa loai te bao B ln 30,6
Limphom nang 22,1
Limphom mo limpho niem mac (MALT lymphoma) 7,6
Limphom te bao T ngoai vi 7,6
Benh bach cau man dong limpho/ Limphom limpho bao nho 6,7
Limphom te bao vung vien 6,0
Limphom te bao B ln cua trung that 2,4
Limphom te bao ln loai thoai san 2,4
Limphom Burkitt 2,5
Limphom vung ra hach 1,8
Limphom nguyen bao limpho T 1,7
Khac 8,6
Di ay la mot so thc the LKH thng gap tai TP. Ho Ch Minh.

(1) Limphom nguyen bao limpho/benh bach cau cap nguyen bao limpho
Limphom/Benh bach cau cap nguyen bao limpho la u cua cac te bao B hoac T cha
trng thanh (cac nguyen bao limpho B hoac T).
- 85% cac trng hp xuat phat t nguyen bao limpho B tuy xng. Trong a so trng
hp, nguyen bao limpho B tang sinh trong tuy xng va/hoac trong mau ngoai vi, bieu hien bang
benh canh benh bach cau cap. Benh bach cau cap nguyen bao limpho B thng gap tre nho.
Mot so t trng hp, nguyen bao limpho B tang sinh tao thanh khoi u ac hach, bieu hien
bang benh canh limphom. Limphom nguyen bao limpho B xay ra benh nhan tre tuoi. Lam
sang thng thay ton thng hach, da, xng. Tren vi the, te bao u xam nhap lan toa mo
hach. Te bao u co nhan tron hoac cuon lai, hach nhan khong ro, phan bao rat nhieu. Ve mat
hnh thai thng khong phan biet c nguyen bao limpho B va T.
- 15% cac trng hp xuat phat t nguyen bao limpho T. Nguyen bao limpho T tang sinh
ac tnh thng tao thanh mot khoi trong tuyen c, phat trien nhanh, thng i kem vi hach, lach
to. Limphom nguyen bao limpho T thng gap benh nhan nam tre tuoi. Hnh anh vi the ac
trng la cau truc hach b xoa, thay the bi cac nguyen bao co kch thc trung bnh, nhan cuon,
hach nhan khong ro, phan bao rat nhieu. Thng co tham nhap cac bach cau a nhan ai toan.
(Hnh 18). Ch co 25% cac trng hp u xuat phat t nguyen bao limpho T bieu hien bang benh
bach cau.
- Benh tien trien nhanh, mau chong lan tran vao cac he c quan, tien lng xau.
- Kieu hnh mien dch: xuat phat t cac nguyen bao limpho T, co TdT+, CD1a+, CD2+, CD5+, CD7+;
neu te bao u giai oan biet hoa muon hn cua nguyen bao limpho T se co them CD3+, CD4+, CD8+. Xuat
phat t cac nguyen bao limpho B, co TdT+, CD19+, PAX5+; neu te bao u giai oan biet hoa muon hn
cua nguyen bao limpho B se co them CD10+, CD20, CD79a+, chuoi nang IgM trong bao tng.
Hnh 18: Limphom nguyen bao limpho T xoa cau truc hach, xam nhap vo bao hach (*) (A); Te bao u co nhan
tron hoac cuon lai (mui ten), hach nhan khong ro, phan bao rat nhieu (B).
(2) Limphom limpho bao nho

Limphom limpho bao nho va benh bach cau man dong limpho la 2 kieu bieu hien khac
nhau cua cung 1 thc the la u cua limpho bao B nho. Limphom limpho bao nho co hach to, tuy
xng cha b te bao u xam nhap nen khong co giam cac dong te bao mau, so lng limpho
bao B nho trong mau ngoai vi < 5x109/L. Trai lai, trong benh bach cau man dong limpho, te bao
u xam nhap vao tuy xng, gay thieu mau, gan lach to va so lng limpho bao B nho trong mau
ngoai vi 5x109/L.
Limphom limpho bao nho thng gap tuoi trung nien va ngi ln tuoi. a so benh nhan
khong co trieu chng lam sang. Benh tien trien cham, kha nang song con rat tot.
Cau truc hach b xoa, thay vao o la hnh anh lan toa mot loai te bao limpho tron nho,
nhan am mau, chat nhiem sac tho, hach nhan khong ro, bao tng rat t. Phan bao hiem gap.
- Kieu hnh mien dch: xuat phat t limpho bao B nho co sIgM+, CD5+, CD10-, CD23+, CD43+,
CD19+, CD20+, CD79a+.
Hnh 19: LKH loai limpho bao nho, cau truc hach b xoa (A); Lan toa mot loai te bao limpho tron nho (B)
(3) Limphom te bao vung vien

La u limpho xuat phat phat t cac te bao B vung vien bao quanh cac trung tam mam.
Limphom te bao vung vien gap ngi ln tuoi, tuoi trung bnh la 60, nam mac benh
nhieu hn n ; benh khong gap tre em. ay la loai LKH tien trien nhanh, khong cha khoi
c, benh nhan thng en giai oan tre III hoac IV ; 1/3 trng hp te bao u xam nhap vao
mau ngoai vi.
Te bao u co kch thc t nho en trung bnh, mang nhan khong eu, co kha, hach
nhan khong ro, bao tng t, tang sinh lan toa trong hach hoac co khi bao chung quanh cac
trung tam mam. (Hnh 20)
- Kieu hnh mien dch: xuat phat t te bao B vung vien pha trong, cha tiep xuc khang nguyen, co
cyclin D1+, CD5+, CD23-, CD19+, CD20+, CD79a+.
Hnh 20: LKH te bao vung vien: te bao u vay quanh tam mam (A); Te bao u co kch thc t nho en trung
bnh, mang nhan khong eu, co kha, hach nhan khong ro, bao tng t (B).
(4) Limphom te bao vung ra

La u limpho xuat phat t cac te bao B vung ra, ngoai vung vien. Limphom te bao B vung
ra co the xay ra hach, lach hoac v tr ngoai hach (mo limpho niem mac MALT lymphoma
thng gap nhat).
hach, limphom te bao B vung ra thng gap ngi ln, tuoi trung bnh la 60, nam n
mac benh bang nhau; benh cung co the gap tre em. a so benh nhan ch co trieu chng hach
ngoai vi to, khu tru hoac toan than. Benh dien tien cham, tien lng kha tot, nhng thng tai
phat. 20% chuyen dang thanh limphom lan toa loai te bao B ln, khi o tien lng benh xau
hn.
Cau truc hach b xoa khong hoan toan. Te bao u giong te bao vung ra, co kch thc thay
oi t nho en trung bnh, nhan tron hoac hi co kha, bao tng kha nhieu va sang. Te bao u
tang sinh lan toa trong vung gia cac nang limpho th cap lam vung nay gian rong, gay chen ep
nang. (Hnh 21)
- Kieu hnh mien dch: xuat phat t te bao B vung ra, co CD20+; CD5-; CD23-; Cyclin D1-; CD10-; bcl6-
; bcl2+; MUM1+/-; IgM+.
Hnh 21: LKH te bao vung ra: te bao u tang sinh trong vung gia cac nang limpho (*), gay chen ep nang (A);
Te bao u co kch thc nho en va, nhan co kha lom, hach nhan khong ro, bao tng sang, (B).
(5) Limphom nang

LKH nang la u cua te bao B thuoc trung tam mam, gom cac tam bao va nguyen tam bao,
sap xep thanh cau truc dang nang.
Thng gap ngi ln tuoi. Tuoi mac benh trung bnh la 60, n hi nhieu hn nam.
ngi da trang, LKH nang chiem t le t 22% en 40%, nhng ngi Chau A t le nay ch t 5-
10%. Ch co 1/3 trng hp benh nhan en giai oan I, II. 40-70% trng hp co lan tran vao
tuy xng. Tien lng thay oi tuy giai oan lam sang va grad mo hoc cua LKH nang.
Hnh 22: So sanh hach tang san nang va limphom khong Hodgkin dang nang: Nang limpho tang san kch
thc to nho, khong eu, con vung tuy hach (A1), Con vien limpho bao nho quanh nang (A2), Nang co hnh
anh a dang te bao, nhieu ai thc bao va phan bao (A3), Te bao tam mam am tnh vi Bcl-2 (A4). Nang
tan sinh ac tnh co kch thc ong eu, phan bo t vung vo en vung tuy hach (B1), Nang khong con vien
limpho bao nho bao quanh (B2), Nang co hnh anh n dang mot loai te bao tan sinh ac tnh (B3), Te bao
trong nang dng tnh vi Bcl-2 (B4).
Te bao u tap trung lai thanh tng nang. Can phan biet hnh anh cua mot LKH dang nang
vi hnh anh tang san nang phan ng cua hach. Nang trong LKH co ac iem: (1) cau truc bnh
thng cua hach b ao lon, nang phan bo t vung vo en vung tuy hach, mat cac vien limpho
bao nho quanh cac trung tam mam; (2) cac nang co kch thc va hnh dang tng oi ong
eu; (3) thanh phan te bao trong nang thng n dang, khong co hien tng thc bao, phan
bao co ca trong nang va ngoai nang, co phan bao bat thng; (4) nhuom hoa mo mien dch, te
bao trong nang dng tnh vi Bcl-2. (Hnh 22)
Trong nang cua cac LKH dang nang co cha 2 loai te bao: (1) te bao nho giong tam bao,
kch thc xap x limpho bao bnh thng, nhan meo mo, co kha, chat nhiem sac tho, hach
nhan khong ro, bao tng rat t; (2) te bao ln giong nguyen tam bao, kch thc gap hai lan
limpho bao bnh thng, vien bao tng ro, nhan sang, co 1-3 hach nhan nam gan mang nhan.
Limphom nang c chia thanh 3 grad da tren so lng nguyen tam bao em c tren
moi quang trng VKx 40: 5 nguyen tam bao --> grad 1; 6-15 nguyen tam bao --> grad 2; >15
nguyen tam bao --> grad 3. Grad 3 co tien lng xau, thi gian song con ngan hn grad 1 va 2.
(Hnh 23)
- Kieu hnh mien dch: Te bao u xuat phat t cac te bao B cua trung tam mam, co sIg+, CD5-, CD10+,
CD43-, CD19+, CD20+, CD79a+, BCL-2+.
Hnh 23: LKH nang: grad 1 (A); grad 2 (B); grad 3 (C)
(5) Limphom lan toa loai te bao B ln

Limphom lan toa loai te bao B ln la u limpho dien tien nhanh cua cac te bao B kch
thc ln (kch thc bang nhan cua ai thc bao hoac ln hn hai lan limpho bao nho), co the
khi phat mi hoac do chuyen dang t mot limphom grad thap. Limphom lan toa loai te bao B
ln la mot nhom khong thuan nhat gom nhieu nhom nho co hnh thai, kieu hnh mien dch, bat
thng ve gen va lam sang khac biet nhau : te bao u xuat phat t te bao cua tam mam (nguyen
tam bao) ; hoac t te bao khong phai cua tam mam (nguyen bao mien dch B) ; hoac do chuyen
dang t mot limphom vung ra ; . . .
Benh gap moi la tuoi, a so tuoi 60-70 tuoi, nhng cung co the gap ngi tre va
tre em. Nam mac benh hi nhieu hi n. 50% giai oan I, II. Benh tien trien nhanh, nhng te
bao u nhay vi hoa tr ; do o, 60-80% benh nhan co the lui benh hoan toan sau ieu tr.
Cau truc hach b xoa, thay the bi tnh trang tang sinh lan toa cac te bao B ln, bao gom
cac te bao giong nguyen tam bao, nguyen bao mien dch va nhng te bao ln khong ien hnh ;
t le phan bao cao. (Hnh 24).
- Kieu hnh mien dch: Xuat phat t cac te bao cua trung tam mam co CD20+, Bcl-6+ lan toa va
ong nhat, CD10+, MUM1-; Neu bcl-6+ khong ong nhat hoac am tnh, CD10-, MUM1+, te bao u co nguon
goc khong phai cua tam mam
Hnh 24: LKH lan toa loai te bao B ln: loai nguyen tam bao (A); loai nguyen bao mien dch (B)
(7) Limphom te bao T ngoai vi, loai khong ac hieu

La 1 loai u limpho cua te bao T ngoai vi ma ac iem vi the cua no khong cho phep xep
vao cac loai limphom te bao T ngoai vi khac a biet, c liet ke trong bang phan loai (nhom IV
Bang 3).
Chiem 30% cac limphom te bao T ngoai vi. a so benh nhan la ngi ln, hiem gap
tre em. T le nam:n la 2:1. a so benh nhan co hach to toan than, oi khi co tang bach cau a
nhan ai toan, nga, sot va sut can. Tien lng xau.
Te bao T ac tnh a dang, kch thc thay oi t trung bnh en ln, nhan tang sac meo
mo, hach nhan ro, t le phan bao cao. Te bao u xam nhap lan toa trong vung can vo, lam cau
truc hach b xoa va thng co kem theo nhieu te bao phan ng nh bach cau a nhan ai toan,
ai thc bao. (Hnh 25)
- Kieu hnh mien dch: Xuat phat t te bao T trng thanh co CD2+, CD3+, CD5+, va thu the te bao
T hoac , mot so co the co CD4+ hoac CD8+.
Hnh 25: LKH te bao T ngoai vi khong ac hieu: Te bao u co kch thc t trung bnh en ln (A); te bao u
tron lan vi bach cau a nhan ai toan (B)
(8) Limphom te bao ln loai thoai san

Limphom te bao ln loai thoai san la u limpho xuat phat t te bao T trng thanh. U gom
cac te bao kch thc ln, a dang va co dau an CD30+.
Benh xay ra hai nh tuoi, mot ngi tre va mot ngi ln tuoi, co the hach hoac
v tr ngoai hach (thng gap nhat la da). a so benh nhan en giai oan tre, hach to toan
than, bieu hien benh v tr ngoai hach, xam nhap tuy xng , co trieu chng nhom B. ngi
tre, thng co chuyen oan gen ALK, bieu hien protein ALK+, tien lng tot. ngi ln tuoi,
khong co chuyen oan gen ALK, bieu hien protein ALK- , tien lng xau.
Te bao u co kch thc ln, d dang,

cha 1 hoac nhieu nhan meo mo, xep
thanh hnh mong nga hoac vong hoa;
hach nhan to ; bao tng nhieu va co
vung ai toan am gan nhan; ay la loai te
bao ch iem limphom te bao ln loai
thoai san. T le phan bao cao va co nhieu
te bao phan ng i kem nh limpho bao
nho, tng bao, mo bao, bach cau a
nhan trung tnh, bach cau a nhan ai
toan. Vo bao va nhu mo hach co the b
x hoa. (Hnh 26)
- Kieu hnh mien dch: xuat phat t te bao Hnh 26: Limphom te bao ln loai thoai san, te bao u a
T trng thanh nhng thng mat bieu hien dang, cha nhieu xep hnh mong nga hoac vong hoa, bao
CD3 ; CD45+, CD45RO+ ; CD2+, CD5+, CD4+ tng ai toan vung canh nhan (mui ten).
trong a so trng hp ; CD30+ hau het te
bao u; EMA+; CD15-.
Sau ay la bang tom tat cac loai LKH chnh thng gap
Bang 5 : Tom tat cac loai LKH chnh thng gap
Chan oan Nguon goc te bao u Hnh thai noi bat Tan suat va ac iem lam sang
U te bao tien B va tien T

Benh bach cau Te bao tien B cua Nguyen bao limpho 85% cac trng hp benh bach cau
cap / Limphom tuy xng co mang nhan khong cap tre em.
nguyen bao eu, chat nhiem sac Chu yeu gap tre em ; trieu chng
limpho B co ac, hach nhan tuy thuoc mc o tuy xng b xam
nho, bao tng t. lan va mc o thieu mau ; dien tien
nhanh.
Benh bach cau Te bao tien T Giong benh bach cau 15% cac trng hp benh bach cau
cap / Limphom (thng co nguon cap/ Limphom nguyen cap tre em. 40% cac trng hp
nguyen bao goc t tuyen c) bao limpho B limphom tre em.
limpho T Chu yeu nam gii tre ; Khoi u
tuyen c, te bao u co the xam nhap
vao tuy xng ; dien tien nhanh.
U te bao B trng thanh (te bao B ngoai vi)
Limphom lan toa Te bao B cua tam Thay oi ; a so giong 40-50% cac limphom cua ngi ln
loai te bao B ln mam hoac sau tam te bao B ln cua tam Moi tuoi, nhng thng gap nhat
mam mam ; xam nhap lan ngi ln tuoi; thng bieu hien di
toa benh canh mot khoi u ln nhanh;
30% v tr ngoai hach; dien tien
nhanh
Limphom te bao Te bao B trng Limpho bao kch 3-4% cac limphom cua ngi ln
vung vien thanh cha tiep xuc thc nho hoac trung an ong ln tuoi ; benh canh lan
khang nguyen bnh, mang nhan tran ; dien tien nhanh trung bnh
khong eu, xam nhap
lan toa
Limphom nang Te bao B cua tam Thng la te bao nho 40% limphom cua ngi ln
mam co kha tron lan vi te Ngi ln tuoi ; hach to toan than va
bao ln ; tao thanh xam nhap tuy xng ; dien tien cham
cac nang ong eu
Limphom limpho Te bao B trng Limpho bao kch 40% limphom cua ngi ln
bao nho/ Benh thanh cha tiep xuc thc nho tang sinh Ngi ln tuoi vi bieu hien benh
bach cau man khang nguyen hoac lan toa; cau truc hach tuy xng, hach, lach va gan ; thieu
limpho bao te bao B nh b xoa so trng hp co tac huyet t mien
va giam tieu cau ; dien tien cham
U te bao T trng thanh (te bao T ngoai vi)

Limphom te bao T Te bao T ho tr Thay oi ; thng la Limphom te bao T thng gap nhat
ngoai vi, khong hoac te bao T oc te mot pho te bao dang ngi ln
ac hieu bao limpho bao kch thc Chu yeu ngi ln tuoi, thng co
t trung bnh en ln hach to; dien tien nhanh
Limphom te bao Te bao T oc te bao Te bao thoai san kch 3% cac limphom ngi ln; 10-
ln loai thoai san thc ln, mot so co 20% cac limphom tre em
nhan hnh mong nga, Benh tre em va ngi tre, thng
bao tng nhieu, xam co bieu hien benh hach va phan
nhap lan toa mem; dien tien nhanh
VI. UNG TH DI CAN HACH

1. Hach la v tr di can rat thng gap cua cac ung th. Tan suat cho di can hach thay oi
khac nhau tuy loai ung th. Cac carcinom va melanom thng hay cho di can hach. Ngc lai,
hiem khi cac sarcom cho di can hach, ngoai tr sarcom c van, sarcom dang bieu mo, sarcom
hoat mac, sarcom khong biet hoa te bao a dang.
2. Te bao ung th di can theo mach bach huyet en hach vung.
Khi au, cac te bao ung th xam nhap
vao cac xoang bach huyet di vo, roi en
cac xoang quanh nang, xoang tuy. Sau o, t
cac xoang bach huyet, te bao ung th tang
sinh xam nhap vao nhu mo hach, hau qua la
cau truc bnh thng cua hach b xoa i, mot
phan hay toan bo mo hach b thay the bi
cac am te bao ung th. Cung co khi do khoi
ung th di can phat trien gay lap tac mach
bach huyet trong hach, dong bach huyet b
trao ngc lai, mang cac te bao ung th vao
hach lan can bang mach bach huyet i cua Hnh 27: Te bao ung th di can en hach theo ng
hach nay va xam nhiem trc tien tai vung bach huyet; oi khi di can ngc dong.
tuy hach. (Hnh 27)
3. Khi a biet khoi ung th nguyen phat, viec khao sat tm hach di can co y ngha het sc
quan trong. Co hay khong co hach di can, cung nh mc o di can la mot yeu to giup anh gia
giai oan ung th e la chon phng phap ieu tr thch hp.
4. Di can hach cung co khi la trieu chng c phat hien au tien cua mot ung th. Thong
thng, khi kch thc khoi ung th nguyen phat cang ln th t le cho di can hach cang tang.
Nhng trong mot so trng hp ung th mui hau, khau hau, khoi ung th nguyen phat co kch
thc rat nho a cho di can hach co. Cung co trng hp hach b di can nhng khong ro o
nguyen phat.
5. Chan oan phan biet gia ung th nguyen phat cua hach va ung th di can en hach
oi khi rat kho khan. Cac ac iem gi y mot ung th di can gom: te bao ac tnh co khuynh
hng ket dnh tao thanh tng o, gii han ro vi mo limpho chung quanh, co the kem theo hien
tng hoai t va tang san xoang phan ng. oi khi tren mo hoc khong phan biet c gia ung
th nguyen phat hay th phat tai hach, ngi ta phai s dung nhng phng phap nhuom ac
biet hoac hoa mo mien dch e xac nh chan oan.
6. V tr hach di can va hnh anh vi the cho nhieu gi y e tm khoi ung th nguyen phat.
Ung th vung san mieng thng cho di can hach di cam. Ung th di can en nhom hach co
cao thng la t ng ho hap va tieu hoa tren. Ung th di can en nhom hach co gia vi hnh
anh nhu tren vi the gi y mot ung th dang nhu nguyen phat t tuyen giap; neu co hnh anh te
bao gai, khoi u nguyen phat co the ng ho hap hay tieu hoa tren nh hau, thanh quan. Ung
th di can en hach tren on a so la t phoi hay tuyen vu. Neu la hach tren on trai, nhieu kha
nang khoi ung th nguyen phat nam da day, tuy, tuyen tien liet va tinh hoan. Ung th di can
en hach nach thng la t tuyen vu. Ung th di can hach ben thng la cac ung th cua c
quan sinh duc ngoai, melanom ac hoac carcinom te bao gai chi di. (Hnh 28)
Hnh 28: Carcinom te bao gai di can hach, mot phan mo hach b xam nhiem bi khoi ung th di can (mui
ten) (A); Te bao gai ung th biet hoa ro tao nhieu cau sng (B).
1. Benh nhan n 52 tuoi b noi nhieu hach co sau mot thi gian c ieu tr vi thuoc chong
ong kinh. Tren mau sinh thiet hach thay vung vo va vung tuy b thu hep do vung can vo ln
rong, co rat nhieu limpho bao nho, nhieu nguyen bao mien dch va cac mach mau tang sinh.
Chan oan phu hp nhat trong trng hp nay la:
A/ Hach viem cap tnh hoai t B/ Hach tang san xoang
C/ Hach tang san vung can vo D/ LKH lan toa loai te bao B ln
E/ Limphom Hodgkin loai giau limpho bao dang cuc
2. Trong Limphom Hodgkin kinh ien, loai te bao nao sau ay la tieu chuan can thiet cho chan
oan:
A/ Te bao Hodgkin B/ Te bao R-S dang hoc
C/ Te bao R-S kinh ien D/ Te bao R-S dang thoai san E/ te bao LP
3. Ung th di can hach co ac iem:

A/ De dang phan biet vi limphom cua hach
B/ Carcinom va melanom t khi cho di can hach
C/ Sarcom thng cho di can hach nhieu nhat
D/ V tr hach di can va hnh anh vi the gi y khoi u nguyen phat
E/ Te bao ung th thng xam nhap trc tien vao xoang tuy
4. Nang limpho tang san trong hach tang san nang co cac ac iem sau, NGOAI TR
A/ Kch thc to nho khong eu
B/ Phan bo vung vo hach
C/ Co vien limpho bao nho bao quanh
D/ Trung tam mam a dang te bao, nhieu phan bao
E/ Trung tam mam dng tnh vi bcl-2 (nhuom hoa mo mien dch)
5. Trong trng hp LKH dang nang grad 3, te bao u tang sinh ac tnh mang kieu hnh mien dch
giong vi loai te bao limpho ang giai oan biet hoa chuyen dang nao sau ay?
A/ Limpho bao B nho B/ Nguyen tam bao C/ Tng bao
D/ Nguyen bao limpho B E/ Te bao B vung ra
Benh Ly Xng Khp Phan mem 333
BENH LY XNG, KHP VA PHAN MEM
Muc tieu:
1. Neu c ac iem benh hoc cua 3 benh xng chuyen hoa.
2. Mo ta hnh thai ton thng gay xng va viem xng tuy xng sinh mu.
3. Neu ac iem dch te hoc va ac iem lam sang - GPB cua 1 so u xng thng gap.
4. Ke ten cac loai benh ly khp, phan biet c s khac nhau ve benh hoc gia
benh thoai hoa khp va viem khp dang thap.
5. Mo ta mot so ac iem chung cua u phan mem.
BENH LY XNG
Nhac lai mo hoc:

Bo xng cua ngi gom 206 cai, khac nhau ve hnh dang va kch thc nhng co the gop
thanh 2 loai chnh: xng ong va xng det. Xng det (xng so, xng c, xng chau) c
hnh thanh trc tiep t trung mo theo kieu cot hoa mang (intramembranous ossification) . Xng
ong c tao ra qua trung gian cua mo sun, nh vao hoat ong cua cac trung tam cot hoa
nguyen phat va th phat tng ng tai phan than va phan au cua mo hnh sun, sau o tiep tuc
gia tang kch thc nh vao hoat ong cua a sun tiep hp, ay la kieu cot hoa trong sun
(endochondral ossification). Ve mat giai phau hoc, xng ong c phan thanh cac 3 vung khac
nhau tuy theo tng quan vi a sun tiep hp (epiphyseal plate): au xng, than xng va
hanh xng. (Hnh 1A)
Tren ai the, moi loai xng eu c tao bi 2 loai mo xng: mo xng ac ben ngoai
va mo xng xop trong; gia cac be xng xop la cac hoc cha tuy xng va m. (Hnh 1B)
Hnh 1: Cac phan giai phau hoc cua mot xng ong (1A), mo xng ac, xng xop va tuy xng.
Tren vi the, n v cau tao can ban cua xng ac va xng xop la cac la xng (lamellae)
xep song song vi nhau (Hnh 2A, 2B). xng ac, cac la xng nay xep ong tam tao thanh
cac he thong Havers, chay song song vi truc cua xng ong.
La xng c tao bi te bao xng, vui trong chat nen xng a c khoang hoa. Chat
nen xng (bone matrix) khi cha c khoang hoa th c goi la chat dang xng (osteoid),
cau tao chu yeu bi cac si collagen typ I, va co them mot so protein khac can thiet cho qua
trnh khoang hoa nh osteocalcin, osteonectin. Khi a c khoang hoa th thanh phan khoang
chat se chiem 65% khoi lng chat nen xng, chu yeu la cac tinh the hydroxyapatit calci
(Ca10(PO4)6(OH)2 ) va mot lng nho phosphat calci.
Hnh 2: Cac la xng xep ong tam tao thanh he Havers cua xng ac (A); cac la xng sep song song
trong cac be xng xop, ngan ra cac hoc cha te bao cua tuy tao huyet va m (B); cac tao cot bao
ang hoat ong tao xng (C); cac huy cot bao ang huy xng (D)
Te bao xng gom 4 loai sau:

- Tien tao cot bao (osteoprogenitor cells): la cac te bao trung mo nam gan be xng, co
kha nang biet hoa thanh cac tao co bao.
- Tao cot bao (osteoblast): la te bao tao xng,co kha nang tong hp ra chat nen xng
- Cot bao (osteocytes): nam trong cac hoc cua la xng , khong con hoat ong tao xng
nhng gi vai tro quan trong trong viec ieu hoa ham lng calci va phosphor huyet tng.
- Huy cot bao (osteoclast): la te bao a nhan (6-12 nhan), xuat nguon t te bao goc thuoc
dong mono bao bach cau hat cua tuy tao huyet, co kha nang san xuat cac enzym tieu huy
chat nen xng. (Hnh 2C, 2D)
Hoat ong cua tao cot bao va huy cot bao luon c phoi hp nhp nhang vi nhau: trong
giai oan xng tang trng, hoat ong tao xng chiem u the hn hoat ong huy xng; khi
c the a en tuoi trng thanh, bo xng a tang trng en cc ai th 2 hoat ong tren c
gi cho can bang, am bao xng luon c tu sa va oi mi hang nam t 5-10% khoi lng;
t sau 35 tuoi, khoi lng xng bat au giam dan do hoat ong huy xng chiem u the hn.
Hoat ong cua tao cot bao va huy cot bao chu tac ong cua nhieu yeu to khac nhau:
- Hormon tuyen can giap (parathyroid hormon, PTH) kch thch huy cot bao tai hap thu
xng, lam tang ham lng calci huyet.
- Vitamin D lam tang hap thu calci va phospho tai ruot, thuc ay s khoang hoa chat dang
xng.
- Calcitonin do te bao can nang tuyen giap tiet ra, tac ong ngc vi PTH, lam c che
hoat ong cua huy cot bao.
Trong c the, bo xng am nhiem cac chc nang :
- Tao khung bao ve cho nao bo, tuy song va cac c quan trong long ngc nh tim va phoi.
- Lam gia cho cac c bam vao e thc hien cac c ong cua c the.
- Cha tuy xng tao mau.
- La ni d tr chnh calci cua c the va mot so ion khac nh phosphat, natri va magne.
I. BENH XNG CHUYEN HOA (metabolic bone diseases)

La cac benh roi loan chuyen hoa co the gay ra cac ton thng th phat xng, bao gom
tnh trang giam khoi lng xng (do mat can bang gia hoat ong tao xng va huy xng)
va/hoac tnh trang giam khoang hoa xng. Sau ay la mot so benh xng chuyen hoa tng
oi thng gap:
A. BENH MEM XNG va BENH COI XNG (Osteomalacia & Rickets):

La benh xng chuyen hoa c ac trng bi tnh trang khoang hoa khong ay u chat
dang xng. Benh xay ra ngi ln c goi la benh mem xng, xng khong c khoang
hoa ay u nen de gay. Benh xay ra tre em c goi la benh coi xng, v xng con ang
tang trng, sun tiep hp cha ong nen bo xng de b bien dang.
Nguyen nhan gay benh thng gap
nhat cua benh mem xng va coi xng la
tnh trang thieu hut vitamin D hoac roi loan
chuyen hoa vitamin D.
Vitamin D can thiet cho c the co san
trong thc an va c hap thu tai ruot;
hoac c tong hp mi t 7-
dehydrocholesterol tai da, di tac ong
cua tia cc tm co trong anh sang mat tri.
Vitamin D nay van con dang cha hoat
ong (cholecalciferol), se c hydroxyl
hoa tai gan thanh 25-hydroxycholecalciferol
va sau o lai c hydroxyl hoa lan th hai
tai than di tac ong cua hormon PTH
cua tuyen can giap e tr thanh dang hoat
ong (1,25-dihydroxy-cholecalciferol).
Chc nang chnh cua vitamin D la
duy tr s on nh ham lng calci va
phospho trong mau, ieu kien can thiet cho
hoat ong khoang hoa tai xng, thong qua
cac tac ong tai ruot, xng va than.
- Tai ruot: kch thch s hap thu calci
va phospho.
- Tai xng: phoi hp vi PTH cua
tuyen can giap, ieu hoa hoat ong cua
huy cot bao va kch thch tao cot bao hoat
Hnh 3: Chuyen hoa vitamin D
ong gay khoang hoa chat dang xng.
- Tai than: kch thch s tai hap thu
calci tai ong than xa.
Nh vay tnh trang thieu hut vitamin D se xay ra khi nguon thc pham khong cung cap u
vitamin D, thieu tiep xuc vi anh nang, kem hap thu tai ruot do cac benh ly ng tieu hoa va
gan mat (th du: benh celiac, benh Crohn, benh ly tac nghen ng mat, v.v.), khi co cac roi
loan chuyen hoa vitamin D bam sinh hoac mac phai (th du thieu hut bam sinh cac enzym can
thiet cho qua trnh hydroxyl hoa vitamin D tai gan va than). S thieu hut vitamin D lam cho xng
khong c khoang hoa ay u, tr nen mem, de gay va co the b bien dang neu xng con
ang trong giai oan tang trng. (Hinh 3)
Hnh thai ton thng:
Trong benh mem xng ngi ln,

chat dang xng do tao cot bao san xuat
khong c khoang hoa ay u nen lai. Mac
du xng khong b bien dang nhng tr nen
yeu va de gay. Tren vi the, cac be xng c
phu bi mot lp chat dang xng day hn bnh
thng gap hang chuc lan (bnh thng khong
day qua 12mcm), co the quan sat de dang khi
nhuom ac biet. (Hnh 4 )
Trong benh coi xng tre em, ton Hnh 4: Trong benh mem xng, cac be xng (mau
thng tap trung tai a sun tiep hp. Tai ay, en) c phu bi mot lp day chat dang xng mau
do sun khong c khoang hoa ay u nen o (PP nhuom von Kassa)
cac huy cot bao khong tieu huy c; qua
trnh cot hoa trong sun b nh tre. a sun tiep hp phnh to do sun van tiep tuc tang sinh trong
khi xng lai mem i v khong c khoang hoa, ket qua bo xng cua tre de b cac bien dang
nh: hop so det vung cham va nho vung tran, long ngc chim bo cau, chuoi hat sn, lng gu,
chan ngan va cong vong Tren vi the, cau truc cua a sun tiep hp b roi loan vi cac te bao
sun phnh to, sap xep lon xon. (Hnh 5)
Hnh 5: Tre coi xng co chan cong vong (A); a sun tiep hp phnh to va cau truc b roi loan (B), so sanh
vi a sun tiep hp bnh thng (C).
Lien he lam sang:

Tuy theo mc o tien trien cua benh mem xng, benh nhan co the ch thay au nhe trong
xng, hoac en mc b tan phe v gay xng (co xng ui, xng sn, xng ot song).
tre em mac benh coi xng, cac bien dang xng co the tang len khi tre i lai, lam tang cac lc
tac ong len bo xng. Khi benh mem xng va benh coi xng cha co bien chng, ieu tr de
dang bang vitamin D va calci.
B. BENH VIEM XNG SI HOA BOC (osteitis fibrosa cystica)

La mot loai benh xng chuyen hoa do tnh trang cng tuyen can giap gay ra.
C che benh sinh:

90% trng hp cng tuyen can giap la do co u tuyen lanh tuyen can giap (parathyroid
adenoma), 10% trng hp con lai la do tang san tuyen can giap (parathyroid hyperplasia). S
tang tiet hormon PTH cua tuyen can giap se tac ong tren:
- Xng: kch thch huy cot bao tang hoat ong huy xng
- Than: tang tai hap thu calci va tang bai xuat phospho, tang tong hp 1,25-dihydroxy-
cholecalciferol
- Ruot: tang hap thu calci mot cach gian tiep qua trung gian cua 1,25-dihydroxy -
cholecalciferol.
Ket qua, hoat ong huy xng tai xng gia tang, ham lng calci trong mau cao nhng
ham lng phospho lai rat thap.
Hnh thai ton thng:
V mot ly do cha ro, hoat ong huy xng xay ra mo xng ac cua vo xng nhieu hn
tai mo xng xop. Cac huy cot bao mang ngoai xng va mang trong xng gam vao cac be
xng, pha rong cac ong Havers va ong Volkmann, lam mong vo xng. Phan tuy xng lan
can b hoa si, xuat huyet va thoai hoa boc, tao ra mot khoi mau nau giong u nen con c goi
la u nau. Tren vi the, co the thay hnh anh cac be xng b gam mon, xung quanh la mo si
cha nhieu huy cot bao va ai thc bao ong hemosiderin. (Hnh 6)
Hinh 6: Ton thng hoa boc mau nau xng sn, con goi la u nau (A), cac huy cot bao gam vao be
xng ac (mui ten, B), ton thng gom nhieu huy cot bao, ai thc bao (C).
Lien he lam sang:

Tnh trang huy xng xuat huyet co the gay au, xng tr nen yeu va de gay. ieu tr
bang cach cat bo u tuyen can giap, hoac cat bt 3 tuyen can giap va phan na tuyen can giap
con lai oi vi trng hp tang san tuyen giap, co the cha khoi cac ton thng xng noi tren.
C. BENH LOANG XNG (osteoporosis):

La mot benh xng chuyen hoa rat thng gap, ac trng bi tnh trang suy giam khoi
lng xng a c khoang hoa (mineralized bone); lam tang nguy c gay xng. Benh loang
xng thng xay ra lan toa tren toan bo he xng, ch mot so t trng hp mi xay ra khu tru
vai xng (thng do khong s dung, nh trng hp liet chi).
oi vi kieu lan toa, phan biet 2 loai:
- Loang xng nguyen phat, xay ra phu n hau man kinh (typ I) va ngi gia > 70 tuoi
(typ II). Nguyen nhan va c che benh sinh cua loai nay cha hoan toan c hieu ro.
- Loang xng th phat, co nguyen nhan va c che benh sinh tng oi ro ret nh:
* Cac roi loan noi tiet: tnh trang cng tuyen can giap (do tang san hoac u tuyen can
giap), cng tuyen giap se lam tang hoat ong huy xng cua huy cot bao.
* Cac benh mau ac tnh nh benh a u tuy, mot so benh bach cau va limphom cung
lam tang hoat ong cac huy cot bao.
* Tnh trang kem hap thu calci, phospho va vitamin D ruot do cac benh ly ng tieu
hoa va benh ly gan.
* Bien chng khi s dung mot so loai thuoc, ac biet la cac corticoid.
Do benh loang xng nguyen phat la loai thng gap nhat nen tren thc te khi noi ti
benh loang xng la co y noi ve loai nay. Sau ay la mot so ac iem cua benh loang xng
nguyen phat.
Dch te hoc:
ngi bnh thng, bo xng tang trng at en khoi lng cc ai trong khoang tuoi
25-35; sau o bat au giam dan theo tuoi tac do hoat ong tao xng khong con theo kp hoat
ong huy xng, vi toc o mat xng trung bnh hang nam vao khoang 0,7% khoi lng xng.
S mat xng thng xay ra nhng vung cha nhieu xng xop nh cac xng ot song va co
xng ui, giai thch ly do v sao cac trng hp gay xng trong benh loang xng lai hay thay
tai ay. My, t le gay co xng ui ngi gia trong o tuoi 80 la 15%, en tuoi 90 la 25%.
ieu hien nhien la neu khoi lng xng cc ai a at c khi trng thanh cang ln th
bien chng gay xng do loang xng ve sau se cang thap. Ngi ta thay ch so cc ai nay
khac biet nhau tuy theo gii va chung toc: gii nam cao hn gii n, ngi da en cao hn da
trang va da vang; do vay, gii n co nguy c gay co xng ui cao gap oi gii nam.
phu n man kinh, toc o mat xng con nhanh hn na, trung bnh moi nam khoang 2%
khoi lng xng ac va 9% xng xop. Do o, 50% phu n man kinh co nguy c b gay xng
so vi t le 2-3% gii nam cung o tuoi.
C che benh sinh:
Tuy cha hoan toan sang to trong benh benh loang xng nguyen phat, nhng co the do
hoat ong tng tac cua nhng yeu to sau:
- Cac bien oi do tuoi: cang ln tuoi th hoat ong cua tao cot bao cang yeu, trong khi o
hoat ong cua huy cot bao van nh trc.
- S suy giam ham lng estrogen o phu n man kinh, se kch thch hoat ong cua huy
cot bao qua trung gian interleukin 1 va TNF.
- S suy giam t nhien cac hoat ong the lc ngi gia, se han che hoat ong tu sa
xng, dan en tang mat xng.
- Che o an khong cung cap u calci, phospho, vitamin D.
Hnh thai ton thng:
Ton thng cua benh loang xng xay ra tren toan the bo xng, nhng c thay ro nhat
nhng ni cha nhieu xng xop nh xng ot song, co xng ui va au di xng quay.
Cac ot song b gay, bien dang, hoac xep xuong. Tren vi the, cac be xng cua vung xng xop
b mong i, phan bo tha tht, ri rac. Vo xng ac cung khong con day nh trc. (Hnh 7)
Hnh 7: So sanh 2 lat cat ngang au xng ui co cung o day, ben trai la cua ngi bnh thng, ben phai
la cua benh nhan loang xng (A). ot song bung gia b ep xep xuong do benh loang xng (B).
Lien he lam sang:

Benh loang xng lam xng de gay; nhat la cac xng phai chu lc nhieu nh co xng
ui, au di xng quay, xng song. Gay lun ot song co the ch gay au hoac a en gu
veo cot song. Gay co xng ui la mot trong nhng nguyen nhan hang au gay tan tat va t
vong ngi gia.
Benh loang xng thng khong bieu hien trieu chng trong nhieu nam cho en khi bien
chng gay xng xuat hien; v vay can phai tm cach phat hien benh sm. Chup X- quang
thng qui khong giup ch nhieu v ch phat hien benh khi bo xng a mat en 30-40% khoi
lng. Hien nay, co nhng phng tien hien ai hn giup anh gia benh loang xng, chang
han nh ky thuat o mat o xng bang tia X kep (DXA scan - dual energy X-ray absorptiometry).
e d phong benh loang xng ngi gia, can cho bo sung Calci, vitamin D va khuyen
khch cac hoat ong the lc. phu n man kinh, co the ieu tr vi estrogen nhng phai can
nhac ve nguy c ung th vu va ung th tuyen noi mac t cung do viec dung thuoc.
II. GAY XNG (fractures):

La ton thng xng rat thng gap. Tuy theo cng o va hng cua lc tac ong, xng
co the gay theo nhieu kieu khac nhau: gay hoan toan, gay canh ti, gay vun, gay di lech, gay
kn, gay h Trong mot so trng hp, xng gay t phat do co san benh ly (nh benh mem
xng, di can xng, v.v.), c goi la gay xng benh ly.
Xng gay co mot kha nang oc ao la co the t sa cha, mien la 2 au xng gay phai
c nan thang truc va co nh tot.
Hnh thai ton thng:
Ngay sau khi xng gay, mot khoi mau tu c hnh thai nhanh chong do cac mach mau
tai ay b t v (Hnh 8A). Mang li fibrin cua khoi mau tu c dung lam gia cho cac bach
cau, nguyen bao si va mach mau tan sinh tien vao. en cuoi tuan le th nhat sau gay xng,
khoi mau tu a c to chc hoa thanh mo hat viem bao quanh 2 au xng gay, goi la can si
hoac tien can xng (procallus). (Hnh 8B)
Hnh 8: Qua trnh tao can xng

Sang tuan th 2 va 3, di tac ong cua cac yeu to tang trng do te bao viem tiet ra nh
PDGF, TGF beta, FGF; cac tien tao cot bao tai mang ngoai xng va mang trong xng se biet
hoa thanh tao cot bao, san xuat ra cac be xng phan ng. Cac be xng nay c phan bo
thang goc vi truc cua xng gay. Cac te bao trung mo co trong mo mem xung quanh cung se
biet thanh cac nguyen bao sun, san xuat cac am sun si va sun trong bao quanh o gay. Mo
sun nay c dung lam gia cho hoat ong cot hoa trong sun, tng t nh a sun tiep
hp. Ket qua can si hoa thanh can xng (callus) chac chan hn, noi 2 au xng gay lai vi
nhau. (Hnh 8C)
T tuan th 4 cho en nhieu thang sau o, cac tao co bao va huy cot bao se phoi hp
hoat ong e tu sa can xng, phuc hoi ong tuy va tai tao hnh dang ban au cua xng gay.
(Hnh 8D)
Khi xng gay a lanh hoan toan,

co khi khong nhan ra c vung gay
trc ay (Hnh 9). Tuy nhien, co nhng
trng hp xng gay b di lech nhieu,
khong c nan chnh va co nh tot,
hoac do b nhiem trung nh trong trng
hp gay h; can si khong the hoa thanh
can xng c va co khi b thoai hoa
boc gia, tao thanh khp gia.
Hnh 9: Xng mac va b gay hoan toan (A); can xng

thay ro 6 tuan sau o(B)
III. VIEM XNG TUY XNG (osteomyelitis)

La tnh trang viem xng va tuy xng gay ra bi cac vi sinh vat nh virut, ky sinh trung,
nam moc va vi khuan. Hai loai thng gap nhat la viem xng tuy xng hoa mu va viem lao
xng tuy xng.
A. VIEM XNG TUY XNG SINH MU (pyogenic osteomyelitis)
Trong hau het cac trng hp, vi khuan t 1 o nhiem khuan ban au co khi rat nhe nh
mun mu ngoai da hoac viem nu rang theo ng mau en xng. Mot t trng hp khac, vi
khuan lan en xng t 1 o nhiem khuan lan can nh viem phan mem quanh xng, hoac c
cay ghep trc tiep vao xng nh trong gay xng h.
90% viem xng tuy xng sinh mu la do Staphylococcus aureus; so con lai do cac vi
khuan gram am nh Escherichia coli, Klebsiella, Hemophilus, Salmonella, Pseudomonas, v.v.
Viem xng tuy xng sinh mu thng xay ra tre em t 5-15 tuoi, gii nam nhieu hn
gii n. V tr cua o viem thng vung au xng va hanh xng cua cac xng dai nh xng
ui, xng chay, xng canh tay va xng quay.
Hnh thai ton thng:
Hnh 10: C che hnh thanh ton thng viem xng tuy xng sinh mu
Vi khuan en c vung hanh xng se tao ra 1 o viem cap tnh (Hnh 10A). oc to vi
khuan cung vi cac enzym phong thch t te bao viem lam cac be xng xop b hoai t hoa mu
(Hnh 10B). Vi khuan va te bao viem co the lan xuong than xng, luon theo he thong ong
Havers tham ra ngoai, tao thanh o ap xe ngay i mang ngoai xng (Hnh 10B). O ap xe nay
gay can tr s cung cap mau nuoi cho vung xng b ton thng, co the khien cho nguyen 1
oan xng b hoai t. Do oan xng chet nay b vui trong am mu nen con c goi la xng
tu (sequestrum) (Hnh 10C). Khi mang ngoai xng b nt v, mu thoat ra tao thanh o ap xe
phan mem. Sau cung, mu co the chay ra ngoai qua mot lo do tren da, keo theo cac manh vun
xng tu (Hnh 10D). ang s nhat la khi o viem lan rong qua au xng en khp, gay ra viem
khp mu. Mat sun khp co the b pha huy hoan toan, e lai di chng tan phe vnh vien. Sau 1
tuan, tai o viem co s tham nhap ngay cang nhieu cac te bao viem man tnh, mo si tang sinh,
cac tao cot bao va huy cot bao tang hoat ong. Tao cot bao tao ra cac be xng phan ng
di mang ngoai xng, bao quanh cac manh xng chet. (Hnh 11)
Hnh 11 : A. Lo do mu ra da (mui ten); B. Manh xng tu (*), nam gia ng do mu.
Lien he lam sang:

Benh nhan co trieu chng sot cao, n lanh, au choi tai vung xng b viem. Benh co the
cha khoi neu ieu tr kp thi bang khang sinh thch hp, ket hp vi rach thoat lu mu. Co t
5-25% trng hp khong ap ng ieu tr, chuyen sang viem xng tuy xng man tnh. oi vi
nhng trng hp nay, ngoai khang sinh, con phai phau thuat nao vet o viem e loai bo toan bo
cac manh xng chet.
B. VIEM LAO XNG TUY XNG

Viet nam thuoc nhom nc ang phat trien, ieu kien kinh te - xa hoi con nhieu kho khan,
do vay benh lao van con kha pho bien, ac biet nhom benh nhan nhiem HIV. c lng co
khoang 1-3% benh nhan lao phoi hoac lao ngoai phoi co kem nhiem khuan xng. Vi khuan lao
en xng chu yeu bang ng mau, mot t trng hp co the theo ng bach huyet hoac phat
tan trc tiep t 1 o viem lao gan xng.
Viem xng tuy xng do lao xay
ra thanh thieu nien nhieu hn ngi
ln; v tr ton thng thng gap nhat la
cac ot song ngc va bung, mot so
trng hp xng ui.
Tai cot song, phan ng viem lao gay
hoai t manh cac be xng xop cua than
ot song, dan en lun xep ot song
khien benh nhan b gu veo. a em co
the b ay ra sau, chen ep len re than
kinh va tuy song, gay au va yeu liet chi.
Chat hoai t ba au co the thoat ra trc
cot song tao thanh ap xe lanh vung c
than lng, chui xuong di va do ra da
vung ben ui. Hnh anh vi the cua viem Hnh 12: ot song b lun xep (A); Ton thng viem lao
xng tuy xng do lao cung tng t 2 than ot song (*) va ap xe lanh c than lng (mui ten) (B)
viem lao ni khac, gom cac nang lao
ba au hoa, xen lan vi cac manh xng
chet. (Hnh 12)
IV. U XNG
U xng tng oi t gap, ch chiem khoang 0,2% tong so cac u bu ngi. ai a so u
xng la nhng trng hp xay ra t phat (de novo), khong co nguyen nhan ro ret. U xng co
the xuat phat t bat ky thanh phan te bao nao co trong xng. V vay, ngoai cac u xng va u
sun, con co the gap nhieu loai u khac nh u si, u c, u m, u mau, limphom, u vo bao than
kinh, v.v.
Theo phan loai cua To chc Y te The gii, u xung c chia thanh 2 loai, u xng lanh
tnh va u xng ac tnh, vi t le u lanh vt troi u ac (T le lanh/ ac = 100/1). Mot vai loai u xng
noi chung la lanh tnh nhng van co 1 t le nho xam nhap tai cho hoac cho di can xa; chung
c xep vao nhom u giap bien ac. Ghi nhan ung th tai BV. Ung bu Tp. Ho Ch Minh (2008)
cho thay u ac tnh cua xng ch chiem 0,7% cac loai ung th.
Mot iem ang chu y la nhieu u loai xng khac nhau co the cho hnh anh vi the gan
giong; e tranh sai lam trong chan oan, can phai nam ro cac thong so di ay vi nhng ly do
sau:
- Tuoi benh nhan: co y ngha trong chan oan, v co loai u xng hau nh ch gap tre
em ma khong thay ngi ln, va ngc lai.
- Loai xng b u: moi loai u xng co khuynh hng xay ra mot so loai xng nhat nh
- V tr u tren xng: moi loai u thng xuat hien mot vung nhat nh cua xng nh au
xng, hanh xng hoac than xng.
- X quang: mot so loai u xng co hnh anh X-quang kha ac hieu cho phep nh hng
ngay chan oan.
Sau ay la mot so loai u xng thng gap:
A. U xng lanh tnh nguyen phat
1. U xng dang xng (osteoid osteoma):

U thng xay ra ngi tre t 10-30 tuoi, gii nam nhieu hn gii n vi t le 2/1.
U co the xay ra moi xng nhng thng gap nhat la vung hanh xng cua cac xng
dai nh xng ui, xng chay, xng canh tay.
Tren x-quang, u co hnh anh mot o can quang kem, gii han kha ro do c bao quanh bi
mot vien mo xng phan ng can quang manh.
Hnh thai ton thng:
U nam trong vo xng ac, hnh tron, gii han ro, mau o, ng knh t 1-1,5 cm (Hnh 13
A,B). Tren vi the, u tao bi cac be chat dang xng va be xng mong do cac tao cot bao san
xuat; gia cac be la mot mo lien ket giau mach mau. (Hnh 13 C,D)
Hnh 13: U la 1 o can quang kem (A); ai the cua u xng dang xng B); u co vien xng phan ng bao
quanh (C); Cac be chat dang xng va xng trong u (D).
Lien he lam sang:

au la trieu chng noi bat cua u xng dang xng, au tang ve em va bien mat ngay
sau khi u c phau thuat nao bo.
2. U sun lanh tnh (chondroma)

La mot loai u xng lanh tnh thng gap (chiem t le 10-25% cac u xng lanh), xay ra
trong o tuoi 10-40. U thng xay ra cac xng ong nho cua ban tay va ban chan; u xuat phat
t mo xng xop pha trong vung than xng.
Tren X-quang, u can quang kem, gii han ro, cha nhieu om calci phan bo rai rac. U lam
than xng phnh to, vo xng mong i.
Hnh thai ton thng:

U co gii han ro, ng knh thng
khong qua 3 cm. U mau xam xanh, co ve
hi trong. Mat o chac, khong co vung
thoai hoa niem. Tren vi the, u cau tao bi
cac am sun trong; cha cac te bao sun co
kch thc ong eu, nhan nho, nam trong
cac o sun. Chat nen sun co the ngam voi,
tao ra hnh anh cac am calci thay c
tren X-quang. (Hnh 14)
Lien he lam sang:
U gay sng au, co the dan en gay
xng benh ly khi vo xng qua mong.
Benh khoi han sau ieu tr bang phau Hnh 14 : U can quang t, co nhieu om calci rai rac (A);
thuat. Tren vi the, u tao bi cac am sun trong (B)
B. U xng ac tnh nguyen phat

1. Sarcom xng (osteosarcoma):
Neu khong tnh en u tuy tng bao (plasma cell myeloma), mot loai u xng xuat phat t
tuy tao huyet; th sarcom xng la loai u ac tnh nguyen phat thng gap nhat, chiem t le 35%
cac u xng ac tnh.
Sarcom xng thng xay ra ngi tre, t 10-25 tuoi; gii nam nhieu hn gii n vi t le
3/2. U thng xuat hien vung hanh xng cua cac xng dai nh au di xng ui, au tren
xng chay va au tren xng canh tay ( goi la co v tr gan goi xa khuyu).
Sarcom xng xuat phat t cac tien tao cot bao nam trong xoang tuy. U phat trien nhanh,
xam nhap va pha huy vo xng ac. Cac tao cot bao di mang ngoai xng b kch thch, tao
ra cac be xng phan ng, ay phong mang ngoai xng. Khi mang ngoai xng b pha v, u
xam nhap vao mo mem xung quanh, kch thch s tao ra cac be xng phan ng xep thang goc
vi be mat xng. V benh nhan thng tre tuoi, sun tiep hp cha ong se gi vai tro cua mot
hang rao ngan chan, nen t thay u xam nhap vao au xng.
Tren X-quang, sarcom xng co hnh anh hon hp va huy xng va tao xng. S hnh
thanh cac be xng phan ng di mang ngoai xng va trong mo mem cho hnh anh tam giac
Codman va tia loe mat tri. (Hnh 15)
Hnh thai ton thng:
ai the:
Sarcom xng co kch thc ln, ng knh t 5-10 cm. U nam vung hanh xng,
thng a pha v vo xng ac va xam nhap vao mo mem xung quanh. U mau xam nau, mat
o co cho mem b, cho cng chac. Mat cat a dang, co nhng vung xuat huyet, hoai t, thoai
hoa boc.
Hnh 15: Hnh anh huy xng - tao xng, tam giac Codman va tia loe mat tri cua sarcom xng vung
hanh xng au di xng ui tren X quang (A); ai the cho thay sarcom xng b chan lai bi
sun tiep hp (B); Sarcom xng a xam nhap ra mo mem (C).
Vi the:
U cau tao bi cac te bao
kch thc a dang, hnh tron,
bau duc hoac hnh thoi; nhan te
bao ln, d dang, hach nhan ro;
co the thay nhieu ai bao nhieu
nhan. T le phan bao cao, nhieu
phan bao bat thng. Cac te
bao u san xuat trc tiep cac be
chat dang xng, an ket thanh
mang li, bao quanh cac manh
xng chet. Cac be chat dang
xng nay cha c khoang
hoa hoac a khoang hoa mot
phan. Trong mot so trng hp,
te bao u co the san xuat mo
sun va mo si (do o co tac gia Hnh 16: Te bao d dang, t le phan bap cao, trc tiep san xuat cac be
phan biet 3 dang vi the cua chat dang xng, an ket thanh mang li.
sarcom xng la sarcom xng tao xng, sarcom xng tao sun va sarcom xng tao si; tuy
nhien s phan biet nay khong quan trong lam v khong co y ngha ve mat tien lng). Cung can
phan biet cac be chat dang xng noi tren vi cac be xng phan ng, do cac tao cot bao bnh
thng mang ngoai xng va trong mo mem tao ra. (Hnh 16)
Lien he lam sang:

Sarcom xng phat trien nhanh gay sng, au; co the dan en gay xng benh ly trong 5-
10% cac trng hp. U hiem khi di can hach nhng sm cho di can theo ng mau en phoi,
mang phoi va cac xng khac (20% benh nhan a co di can phoi vao thi iem chan oan).
Sarcom xng la loai ung th co o ac tnh cao va tien lng xau; trc ay, t le song 5 nam
sau phau thuat ch at 20%; hien nay a tang en 60% nh phoi hp vi hoa tr trc va sau
mo.
2. Sarcom sun (chondrosarcoma)
La u xng ac tnh nguyen phat xep hang th hai sau sarcom xng, chiem t le 35% cac u
xng ac tnh. Sarcom sun thng xay ra ngi ln, t 30-60 tuoi; gii nam nhieu hn gii n
vi t le 3/1.
U thng gap xng chau, xng ui, xng canh tay va xng sn; hiem thay cac
xng ban tay va ban chan. oi vi cac xng dai, u cung u xuat phat t mo xng xop pha
trong vung than xng, tng t u sun lanh tnh. Tren X-quang, u co hnh anh huy xng vi
cac om voi hoa rai rac, than xng phnh to; vo xng ac day len vi mat trong b gam nham
nh, nhng khong co phan ng mang ngoai xng. (Hnh 17A)
Hnh thai ton thng:
ai the: u co kch thc ln, ng knh t 5-10cm, gii han khong ro, mau xam xanh; mat
o khong eu, co cho mem b, cho cng chac. Mat cat a dang vi nhng vung xuat huyet,
hoai t, thoai hoa niem va thoai hoa boc. (Hnh 17B)
Vi the: u cau tao bi cac am sun rat giau te bao. Cac te bao sun ac tnh nam trong cac o
sun co hnh dang va kch thc khac nhau, nhan ln, tang sac; t le phan bao tang. Tuy theo
mat o te bao, mc o d dang te bao va ch so phan bao, u c xep o mo hoc thanh sarcom
sun grad 1, 2 va 3 (Hnh 17 C, D). Trong u, co the thay nhng vung hoai t, thoai hoa niem va
thoai hoa boc. Gia cac am sun ngoai vi cua u, co the thay cac be xng, bang chng cua
hien tng xam nhap te bao u vao mo xng lanh va khoang tuy.
Hnh 17 : X-quang sarcom sun, vung huy xng, than xng phnh to, day vo xng ac (A); Hnh anh ai
the (B); Vi the sarcom sun grad 1 (C) va grad 3 (D)
Lien he lam sang:

Sarcom xng sun phat trien cham hn so vi sarcom xng, gay sng au. U hau nh
khong cho di can hach nhng thng cho di can theo ng mau en phoi. ieu tr bang phau
thuat, co the phoi hp them vi hoa tr. Tien lng song them 5 nam la 80% oi vi sarcom sun
grad 1, nhng ch con 40% oi vi sarcom sun grad 3.
C. U xng giap bien ac

1. U ai bao xng (giant cell tumor):
U thng xay ra trong o tuoi 20-40, gii nam hi t hn gii n vi t le 4/5. U thng xuat
hien phan au cac xng dai nh au di xng ui, au tren xng chay, au tren xng
canh tay (cung la v tr gan goi xa khuyu nh sarcom xng). Tren X-quang, u co hnh anh huy
xng, gii han kha ro do co phan ng mo xng phan ng bao quanh. U lam au xng phnh
to va mong vo xng. U co the lan rong vao khp nhng hiem khi i xuong vung hanh xng va
than xng. (Hnh 18 A)
Hnh 18: Hnh anh X-quang (A) va ai the cua u ai bao xng (B); te bao u n nhan va ai bao trong u
ai bao xng (C).
Hnh thai ton thng:

ai the: U co kch thc thay oi, co the ln tren 10cm. U co mau nau o, mat o mem,
mat cat a dang, vi nhng vung hoa si, hoai t va xuat huyet. (Hnh 18B)
Vi the: U cau tao bi 2 loai te bao tron lan vi nhau, te bao n nhan va ai bao nhieu
nhan giong huy cot bao (v vay trc ay, u nay c at ten la u huy cot bao - osteoclastoma).
Cac nghien cu gan ay a chng minh rang chnh cac te bao n nhan mi la te bao u, xuat
phat t cac te bao trung mo nguyen thuy; hoat ong cua cac te bao nay mi kch thch s hnh
thanh va biet hoa cac huy cot bao t te bao tien than cua chung. (hnh 18C)
Lien he lam sang:
U gay sng au, dan en gay xng benh ly trong 5-10% trng hp. ieu tr bang phau
thuat. U ai bao xng c xep vao loai giap bien ac v tuy ai a so trng hp co dien tien
lanh tnh, van co khoang 25% tai phat tai cho sau mo va 4% cho di can theo ng mau en
phoi.
D. U xng th phat do di can

Co xuat o cao hn u xng nguyen phat. Hn
80% di can xng xuat phat t ung th nguyen phat
vu, phoi, tuyen tien liet, tuyen giap va than. Di can
xng co the xay ra nhieu xng cung luc, trong
o xng song la ni b di can thng gap nhat.
xng dai, o di can thng thay vung hanh
xng.
Tren X-quang, di can xng thng co hnh
anh huy xng (75%), mot so cho hnh anh tao
xng (15%) hoac phoi hp va huy xng va tao
xng (10%).
ang chu y la khong phai te bao u di can en
xng trc tiep gay huy xng hoac tao xng;
nhng bang cach san xuat cac chat trung gian hoa
hoc tac ong len hoat ong cua cac huy cot bao va Hnh 19: Cac o di can xng song (mui ten
tao cot bao tai cho. (Hnh 19) A); vi the cua carcinom tuyen vu, cac te bao
Tren lam sang, cac o di can xng thung gay ung th (mui ten), kch thch huy cot bao
au, co the lam gay xng neu xng b huy qua (HCB) pha huy xng (B).
nhieu. ieu tr bang tia xa vi muc ch giam au.
Bang sau ay tom tat cac iem khac biet chnh gia cac loai u xng nguyen phat.
BENH LY KHP
Nhac lai mo hoc:
Khp la phan noi gia hai hoac nhieu xng, cho phep c the thc hien cac chuyen ong.
Tuy theo bien o chuyen ong, phan biet 2 loai khp chnh la khp ong va khp bat ong.
Trong khp ong, 2 au xng c sun khp che phu va co mot khoang trong nam gia
goi la khoang khp, cha dch khp (khoang 1-4ml). Khoang khp c gii han ben ngoai bang
mot mo si ac, goi la bao khp. Toan bo mat trong bao khp (ch tr be mat sun khp) c lot
bi mang khp. (Hnh 20)
Hnh 20: S o cau tao khp ong (A); Sun khp nam ta tren ban xng di sun (B);
Bao khp co mang khp phu ben tren (C).
Mang khp c tao bi 1-3 lp te bao mang khp hnh vuong, nam ta trc tiep tren mot
mo lien ket long leo giau mach mau; kieu cau tao nay tao thuan li cho qua trnh trao oi chat
gia mach mau va dch khp. Mang khp san xuat ra dch khp; la mot dch trong, nht; giup
boi trn va nuoi dng be mat sun khp.
Sun khp la mot mo sun trong, be mat lang bong, day 2-4mm; gom 2 lp, lp sun khong
calci hoa tren va lp sun calci hoa di. Lp di nam ta tren mot ban xng xop cua au
xng, goi la ban xng di sun (subchondral bone plate) (Hnh 20B). Thanh phan hoa hoc
cua sun khp cha nhieu nc, khoang 80%; phan con lai gom co cac si collagen typ 2,
proteoglycan, glycosaminoglycan va mot so phan t khac. Cau tao hoa hoc nay lam cho be mat
sun khp co kha nang chong mai mon va chu c cac lc tac ong do chuyen ong gay ra.
Te bao sun khp gi vai tro rat quan trong trong viec duy tr mot sun khp thng xuyen c
oi mi va hoat ong bnh thng, nh vao kha nang thc hien cung luc 2 qua trnh trai ngc
nhau la tong hp va tieu huy chat nen sun.
Sau ay la mot so benh ly khp thng gap.
I. BENH THOAI HOA KHP (degenerative joint disease):
ay la benh ly khp thng gap nhat, ac trng bi tnh trang bao mon tiem tien cua sun
khp. Benh nay trc ay c at ten la benh viem khp xng (osteoarthritis); ay la mot ten
goi khong chnh xac, v phan ng viem ch ong mot vai tro th yeu (hoac khong co) trong c
che benh sinh.
Phan biet 2 loai thoai hoa khp, thoai hoa khp nguyen phat va thoai hoa khp th phat.
- Thoai hoa khp nguyen phat chiem a so, 95% cac trng hp; nguyen nhan gay benh
cha ro.
- Thoai hoa khp th phat chiem 5% cac trng hp, co nguyen nhan ro ret nh chan
thng, h mat khp bam sinh, nhiem trung, lang ong cac tinh the muoi khoang tren mat
khp
Dch te hoc va c che benh sinh cua benh thoai hoa khp nguyen phat:
Benh thoai hoa khp nguyen phat co xuat o tang dan theo tuoi tac: trieu chng thung
xuat hien sau tuoi 40; qua tuoi 50, 40% dan so co bieu hien benh va t le nay tang dan en 80-
90% tuoi 70. Nh vay, mac du nguyen nhan cua benh thoai hoa khp nguyen phat cha c
ro nhng co the la do tnh trang lao hoa t nhien cua sun khp; th du nh s gia tang ham
lng nc cua sun khp, s thoai hoa cac si collagen va proteoglycan, s gia tang hoat ong
tieu huy chat nen sun cua cac te bao sun. Benh thoai hoa khp nguyen phat hay xay ra
nhng khp phai chu tai nang nh khp hang, khp goi, cac khp lien ot song co.
Hnh 21: S hnh thanh cac ton thng trong benh thoai hoa khp
Hnh 22: Vung ban xng di sun lo ra (*) (A); Vung ban xng di sun lo ra (1), boc di sun (2), phan
sun khp cha bong (3) (B); Vet nt tren be mat sun khp (C); Boc di sun (mui ten) (D).
Hnh thai ton thng:

Thay oi tuy theo giai oan benh. Trong giai oan au tien, ch mi co nhng thay oi sinh
hoa cha quan sat c nh s gia tang ham lng nc cua sun khp, s thoai hoa cac si
collagen va proteoglycan. Tiep theo la s xuat hien nhng vet nt tren be mat lam sun khp co
dang hat, mat o mem hn bnh thng. Sau cung, sun khp b bong troc, e lo ra ban xng
di sun. Ban xng nay phai ong vai tro cua be mat khp, b mai nhan bong va day len do
qua trnh co xat trong cac chuyen ong (hien tng hoa nga - eburnation). Ban xng cung co
the b nt v tiep tuc, cho phep dch khp chui xuong, tao thanh cac boc di sun (subchondral
cyst). Trong khoang khp co the thay cac manh vun cua sun khp va ban xng di sun b rt
vao.
Ngoai ra sun khp, co the thay cac gai xng moc ra. Bao khp co the hi day len va
cha mot t te bao viem kinh nien. Hnh anh X-quang tng ng gom co hep khoang khp do
mat sun khp, ban xng di sun day, boc di sun va gai xng. (Hnh 21, 22)
Lien he lam sang:
Trieu chng thng thay ro sau 50 tuoi, gom co sng au khp (tang len khi c ong),
cng khp buoi sang, c ong nghe tieng lach tach trong khp (do s co sat gia cac ban
xng di sun). Benh tien trien t t trong nheu nam, co the dan en tnh trang tan phe do
khp h hoan toan. en nay van cha co phng phap phong nga va ieu tr nao thc s co
hieu qua, ngoai tr bien phap thay khp nhan tao.
II. VIEM KHP DANG THAP (rheumatoid arthritis):

nh ngha:
Viem a khp dang thap (VKDT) la mot benh ly viem man tnh co tnh he thong, tac ong
len nhieu mo va c quan khac nhau nh da, mach mau, tim, phoi, c. Tuy nhien khp xng lai
la ni b ton thng nang ne nhat, vi tnh trang viem tang san bao khp, gay pha huy sun khp
va dnh cng khp. (Hnh 23).
c lng co khoang 1% dan so mac benh VKDT, hau het benh nhan trong o tuoi 30-
60, gii n b nhieu hn nam t 3-5 lan.
Hnh 23: Bien dang khp co tay va ngon tay (A); X-quang: hep khe khp, ngon tay lech tru(B).

Mac du nguyen nhan gay benh cha c biet ro; hien nay, benh VKDT c xem nh
mot benh t mien, xay ra nhng ngi co c a di truyen phu hp sau khi tiep xuc vi mot
khang nguyen gay viem khp nao o (arthritogenic antigen). Co nhng bang chng ve yeu to c
a di truyen de mac benh nh:
- Xuat o benh VKDT gia tang trong nhng gia nh a co ngi mac benh.
- S gia tang t le phu hp cac tre sinh oi ong hp t.
- S gia tang t le nhom allen HLA-DR (DR4, DR1, DR10, DR14) so vi ngi bnh thng.
Nh vay nhng benh nhan co c a di truyen phu hp nay, cac limpho bao T CD4+ sau
khi c hoat hoa bi khang nguyen gay viem khp (co the la mot vi khuan, virut hay mot t
khang nguyen nao o), se tiet ra nhieu chat trung gian hoa hoc ma quan trong nhat la TNF va
Interleulin-1 , tac ong len hoat ong cua hang loat te bao khac nh:
- Te bao noi mo mach mau tang bieu hien cac phan t ket dnh, thu hut va tap trung cac
te bao limpho va ai thc bao tai khp.
- ai thc bao se kch thch cac te bao mang khp va nguyen bao si tang sinh tao thanh
mang si, ai thc bao tiet ra cac enzym tieu am nh collagenase, elastase gay pha huy sun
khp va mo xng lan can.
- Cac te bao mang khp va te bao sun san xuat cac enzym tieu am, pha huy chat nen
sun cua sun khp.
- Limpho bao B bien thanh tng bao, san xuat cac t khang the chong lai khp, th du
nh yeu to dang thap (Mot t khang the IgM chong lai IgG, co trong huyet thanh cua 80% cac
benh nhan). Phc hp t khang the - khang nguyen lang ong trong khp va mo ngoai khp
lam nang them phan ng viem va pha huy mo nhieu hn.
- Limpho bao T co the kch thch cac huy cot bao gia tang hoat ong huy xng.
S tng tac gia cac te bao tren se dan en s hnh thanh mang si, pha huy sun khp
va mo xng di sun, dan en tnh trang dnh cng khp. (Hnh 24)
Hnh 24: C che benh sinh cua benh viem khp dang thap
Hnh thai ton thng:

Trong benh VKDT, ton thng khp thng co tnh chat oi xng, xay ra cac khp nho
cua ban tay va ban chan, khp co chan, khp goi, khp co tay, khp khuyu va khp vai. Khi
khp b pha huy, hoa si va dnh cng; co the thay cac bien dang khp nh ngon tay lech tru,
co tay lenh quay. Tren X-quang, co hnh anh hep khe khp do mat sun khp, mo xng quanh
khp giam o can quang (Hnh 23B).
Hnh 25: Mang khp bnh thng (A), Tang sinh te bao mang khp (B), Mang khp tao nhu (C), Mang si
phu len sun khp (D), hoa si va hoa voi gay cng dnh khp (E).
Hnh anh vi the trong giai oan au cua benh VKDT cho thay mang khp b phu ne, tham
nhap nhieu tng bao, limpho bao va ai thc bao; cac mach mau tan sinh, dch xuat fibrin c
tiet ra tren be mat bao khp hoac tao thanh hat troi noi t do trong dch khp. Mang khp day
len, do te bao mang khp tang sinh, gom 8-10 lp te bao (so vi bnh thng ch co 3-4 lp); mo
em cha nhieu tng bao, limpho bao va cac nang limpho. Mang khp gap nep tao thanh nhu
tho vao khoang khp, hnh thanh mang si (pannus) che phu be mat sun khp lam no b cach ly
khoi nguon nuoi dng la dch khp. Ket qua la sun khp va ban xng di sun se b pha huy
dan. Cuoi cung, mang si xam chiem toan bo khoang khp, hoa si va hoa voi, gay dnh cng
va bien dang khp. (hnh 25, 26)
Hnh 26: Te bao mang khp tang sinh (A), Mang khp tao nhu (B), Mang si (*) phu len mat sun khp (C).
Ngoai ra, cac benh nhan VKDT nang, co the gap them nhng ton thng khac ngoai
khp nh:
- Not thap di da (rheumatoid nodule), c thay 25% benh nhan. Not co hnh tron
hoac bau duc, ng knh 2cm, mat o chac, khong au, thng gap cang tay, khuyu tay,
vung cham va lng di. Ve vi the, cau tao cua not thap gom mot trung tam hoai t dang fibrin,
bao quanh bi cac te bao dang bieu mo, limpho bao va tng bao. (Hnh 27)
Hinh 27: ai the not thap di da (A); vi the: trung tam hoai t dang fibrin (*,B)
- Viem mach hoai t cap tnh (acute necrotizing vasculitis), viem mang tim t huyet, viem
mang phoi t huyet, viem mong mat, viem ket - giac mac.
Lien he lam sang:
Benh nhan co trieu chng viem khp oi xng, cng khp buoi sang; thng xay ra cac
khp nho cua ban tay va ban chan. Khp sng to, au, han che c ong. Benh tien trien t t,
vi nhng chu ky giam benh - tai phat, cuoi cung dan en cng dnh va bien dang khp sau
khoang 10-15 nam. ieu tr bang cac thuoc khang viem khong phai steroid, cac thuoc c che
mien dch, nham c che phan ng viem tai khp.
III. BENH GUT (gout):

Benh gut thc ra la mot nhom gom nhieu benh, co ac iem chung la tnh trang tang axt
uric trong mau va lang ong tinh the urat natri khp va than, gay ra viem khp va soi than.
Phan biet 2 loai benh gut:
- Gut nguyen phat: chiem 90% trng hp, cha ro nguyen nhan gay benh, nhng co the
la mot roi loan chuyen hoa bam sinh gay giam bai tiet acid uric tai than.
- Gut th phat: chiem 10% trng hp, co nguyen nhan la cac benh ly lam tang s tong
hp axt uric, th du nh cac benh ung th mau.
Hnh thai ton thng:
S lang ong tinh the urat natri co the gay ra nhieu dang ton thng khac nhau:
- Viem khp cap: bach cau a nhan tham nhap vao bao khp va dch khp. Bao khp
sung huyet, phu ne. Co the thay cac tinh the urat natri hnh kim nam trong bao tng bach cau
a nhan hoac ket thanh am nho trong bao khp. (Hnh 28)
Hnh 28: Viem khp cap do gut (A); Tinh the urat natri hnh kim thay c di knh hien vi phan cc
- Viem khp man tnh: sau nhieu t viem cap tnh, urat lang ong ngay cang nhieu vao
trong bao khp va tren ca be mat sun khp. Mang khp tang sinh, bao khp day len, hoa si va
tham nhap te bao viem kinh nien. Mang si co the c hnh thanh, pha huy sun khp va
xng, dan en dnh cng khp.
- Not Tophi: la ton

thng ac trng cua benh
gut; thng thay sun khp,
gan c, day chang va mo
mem quanh khp. Cac not
tophi nam nong co the loet ra
da. Cau tao vi the cua not
tophi la mot am ln tinh the
urat, c bao quanh bi cac
te bao viem kinh nien nh
limpho bao, ai thc bao va
cac ai bao an d vat. (Hnh
29)
Cac benh than do lang ong
urat nh not tophi trong vung Hnh 29: Not tophi khp ban-ngon chan cai va mo mem
tuy than, soi than, viem be quanh khp (mui ten, A); vi the not tophi (B)
than - than.
Lien he lam sang:

Benh gut xay ra gii nam nhieu hn gii n, trieu chng thng bat au xuat hien sau 30
tuoi. Trong t viem khp cap, ton thng thng ch xay ra vai khp, ac biet la khp ban -
ngon cua ngon chan cai (50% trng hp). Benh tai i tai lai nhieu lan va sau khoang 10 nam
th chuyen sang dang viem khp man tnh; benh tiep tuc tien trien, dan en dnh cng khp. Ton
thng than do lang ong urat co gay suy than lam benh nhan t vong. ieu tr bang cac thuoc
khang viem va thuoc lam ha acid uric mau.
U PHAN MEM (soft tissue tumors)

Phan mem (soft tissue) bao gom tat ca cac mo lien ket trong c the ma khong thuoc ve he
thong xng, khp, than kinh trung ng, mo tao huyet va mo limpho. U phan mem co the xuat
hien bat ky ni nao trong c the, nhng thng nhat la cac chi.
Theo dien tien sinh hoc, phan biet 3 loai u phan mem:
- U phan mem lanh tnh, chiem ai a so (t le lanh/ac: 100/1); u dang cuc, thng nam
nong, kch thc nho (95% nho hn 5 cm), gii han ro, co vo bao. Cau tao vi the y het mo bnh
thng. ieu tr khoi han bang phau thuat.
- U phan mem ac tnh, con goi la sarcom phan mem, ch chiem 0,9% cac ung th ngi
(ghi nhan tai BV. Ung bu Tp. HCM, 2003). U ln nhanh, thng co kch thc ln (> 5cm),
nam sau, gii han khong ro va khong co vo bao. U co the xuat hien bat ky v tr nao tren c
the, nhng 75% trng hp la cac chi (nhat la ui), 10% than va vung sau phuc mac. Xuat
o sarcom phan mem tang dan theo tuoi tac, tuoi trung bnh la 65 (tuy nhien tre em cung co
the gap u phan mem ac tnh, th du sarcom c van). Cac loai u ac thng gap nhat theo th t
giam dan la sarcom khong biet hoa te bao a dang, sarcom m, sarcom c van, sarcom c trn,
sarcom mang khp, u vo bao than kinh ac va sarcom si.
Sarcom phan mem co the di can theo ng mau en phoi va gan; rat hiem khi cho di
can hach (ngoai tr sarcom c van, sarcom dang bieu mo, sarcom hoat mac, sarcom khong
biet hoa te bao a dang). ieu tr chu yeu bang phau thuat, nhng phai phoi hp them xa tr
va hoa tr oi vi cac u ac co grad mo hoc cao. Tien lng benh nhan c anh gia da theo
grad mo hoc cua u va giai oan lam sang .
He thong xep Grad mo hoc sarcom phan mem theo Hiep hoi cac Trung tam
Phong chong Ung th Phap quoc (FNCLCC: Federation Nationale de Centres de
Lutte Contre le Cancer)
o biet hoa cua te bao u: iem

Sarcom giong trung mo bnh thng 1
Sarcom co hng biet hoa ro 2
Sarcom khong biet hoa / khong xac nh loai 3
Ch so phan bao:
0-9 PB / Quang trng VKx40 1
10-19 PB / Quang trng VKx40 2
20 PB / Quang trng VKx40 3
Mc o hoai t u
Khong co hoai t 0
< 50% hoai t 1
50% hoai t 2
Grad 1 : 2 -3 iem Grad 2 : 4 -5 iem Grad 3 : 6 8 iem
- U phan mem giap bien ac: la cac u co dien tien sinh hoc nam trung gian gia 2 loai
tren. U xam nhap tai cho, de tai phat sau phau thuat nhng hiem khi cho di can.
Nguyen nhan gay ra u phan mem van cha c ro; mot so tac gia a neu len vai tro cua
yeu to di truyen, moi trng, bc xa ion hoa, virut, seo cu, v.v. nhng co ve nh ai a so u
phan mem eu la nhng trng hp xuat hien t phat mi (de novo).
Theo quan iem hien nay, u phan mem xuat phat t cac te bao trung mo a tiem nang co
san trong phan mem hoac t tuy xung chuyen en; khi te bao nay chuyen dang thanh te bao
u, co the tang sinh va biet hoa theo nhieu hng khac nhau e tao ra u si, u m, u c, u mach
mau... hoac mot u chang co hng biet hoa nao ro ret. V vay, u phan mem rat a dang, viec
phan loai kho khan va se con tiep tuc thay oi do khong ngng c bo sung nhng hieu biet
mi ve hoa mo mien dch, di truyen hoc te bao va sinh hoc phan t. Bang phan loai u phan
mem mi nhat do To chc Y te the gii a ra nam 2013 liet ke 11 nhom u phan mem, gom
khoang 100 loai khac nhau, trong o 50 loai la sarcom.
I. U m VII. U mach mau

II. U si VIII. U mo em da day ruot
III. U mo bao si IX. U vo bao than kinh
IV. U c trn X. U co hng biet hoa khong ro ret
V. U chu bao XI. Sarcom khong biet hoa/ khong xac nh loai
VI. U c van
I. U M (lipomatous tumors):
1. U m lanh (lipoma):
La loai u phan mem lanh tnh thng gap nhat, xay ra ngi ln t 40 - 60 tuoi. U mau
vang, gii han ro, co vo bao; kch thc trung bnh khoang 3 cm. U hay gap vung co, lng, vai,
bung. Tren vi the, u cau tao nh mo m bnh thng. (Hnh 30)
Hnh 30: U m lanh co mau vang, gii han ro, co vo bao (A); Vi the giong mo m bnh thng (B)
2. Sarcom m (liposarcoma)
Cung la mot loai u thng gap; ch ng sau sarcom khong biet hoa te bao a dang. U xay
ra ngi ln t 40 - 70 tuoi. U co the at kch thc rat ln (tren 10 cm), hay thay vung ui
va sau phuc mac. U xam nhap tai cho, hay tai phat sau phau thuat, di can theo ng mau en
phoi. Tren vi the, u cau tao bi cac te bao m t nhieu giong te bao m bnh thng, tuy nhien
luon co cac nguyen bao m (lipoblast), la ieu kien tien quyet e chan oan sarcom m. (Hnh
31)
Hnh 31: Sarcom m co kch thc tren 10 cm (A), te bao u giong te bao m bnh thng nhng luon co
nguyen bao m (mui ten, B), nguyen bao m cha nhieu khong bao m trong bao tng, an lom
nhan (C)
II. U SI ( Fibrous tissue tumors)

1. U si lanh cua mang gan (fibroma of tendon sheath):
La u lanh tnh, thng gap gii nam t 30 - 50 tuoi. U co dang cuc, gii han ro, ngon
tay hoac ban chan, dnh vao mang gan. Cau tao vi the la mot mo si collagen ac, vi cac
nguyen bao si nam rai rac. (Hnh 32)
Hnh 32: U si cua mang gan ngon 3 (A); cau tao vi the (B)
2. Sarcom si (fibrosarcoma):
Xay ra chu yeu ngi ln t 30 - 60 tuoi. U nam sau, dang cuc, gii han ro nhng khong
co vo bao, kch thc t 3 - 8 cm, mat o chac; v tr thng gap nhat la chi di. Tren vi the,
cac te bao u hnh thoi giong nguyen bao si, xep thanh bo bat cheo nhau nh xng ca, t le
phan bao cao. (Hnh 33)
Hnh 33: Sarcom si phan sau ui, gii han ro, nam gia khoi c van (A); cau tao vi the, te bao hnh thoi
xep bo bat cheo nhau, nhieu phan bao (mui ten, B).
III. U MO BAO SI (fibrohistiocytic tumors):

U mo bao si lanh (fibrous histiocytoma):
U xay ra ngi ln t 20-40 tuoi. U dang cuc khong au, nam nong trong lp b va mo
di da hoac nam sau ben trong cac bo c cua chi, hau het co kch thc nho hn 3 cm; Tren vi
the, cac te bao u co nhan hnh thoi giong nguyen bao si hoac hnh bau duc giong mo bao, xep
thanh bo phan bo kieu xoay loc (storiform), tron lan vi cac te bao bot va ai bao Touton. (Hnh
34)
Hnh 34 : U dang cuc trong lp b da (A) ; Cac te bao u hnh thoi xep bo xoay loc va ai bao Touton (B).
IV. U C TRN ( Smooth muscle tumors)

1. U c trn lanh (leiomyoma):
Thng xay ra ngi tre 15 - 25 tuoi, u nam trong da, co dang mot cuc n oc hay
nhieu cuc, ng knh 1- 2 cm, gii han khong ro. Tren vi the, u tao bi cac bo te bao c trn
giong c trn bnh thng; khong co hnh anh phan bao. (Hnh 35)
Hnh 35: U co dang nhieu cuc tren da (A); vi the, te bao u tao bo giong bo c trn bnh thng (B)
2. Sarcom c trn (leiomyosarcoma):

Xay ra gii n nhieu hn gii nam, tuoi trung bnh la 60.
Hnh 36: Sarcom c trn sau phuc mac kch thc ln, mat cat ac chac nh tht, co cho xuat huyet
hoai t (A); vi the gom te bao hnh thoi d dang, xep bo, co nhieu phan bao (mui ten,B)
U thng xuat hien trong vung sau phuc mac va trong o bung. U co kch thc rat ln
(trung bnh khoang 16 cm), mat cat mau trang xam, xen lan nhng vung hoai t, xuat huyet va
thoai hoa boc. Tren vi the, u tao bi cac te bao co nhan hnh thoi giong te bao c trn bnh
thng (nhan hnh ieu x ga), xen lan vi cac te bao d dang, xep thanh bo; t le phan bao cao.
(Hnh 36)
V. U C VAN (skeletal muscle tumors):
1. U c van lanh
(rhabdomyoma):
Co the xay ra moi
la tuoi, thng gap vung
au co. U co dang cuc, gii
han ro nhng khong co vo
bao, kch thc trung bnh
khoang 3 cm, mat cat dang
hat mn, mau nau o. Tren
vi the, u tao bi cac te bao
a dien, nhan nho lech ben
va bao tng rat ai toan, co
the co khong bao. (Hnh 37) Hnh 37: U c van lanh vung co, mat cat o mn nh tht (A); Vi the te bao
co nhan lech, bao tng ai toan, co khong bao (B).
2. Sarcom c van (rhabdomyosarcoma):

La loai u phan mem ac tnh hay gap nhat tre em, v tr thng thay la vung phan mem
canh tinh hoan, am ao va vung au co. U co kch thc trung bnh 3 - 4cm, gii han khong ro,
mat o chac, mat cat dang hat mn, mau nau o, co xen lan nhng vung xuat huyet hoai t. Cau
tao vi the a dang, vi cac te bao u hnh tron, hnh thoi hoac a dien, nhan tang sac, bao tng
ai toan co cha cac van c giong cac nguyen bao c van (rhabdomyoblast); t le phan bao tang.
Sarcom c van la loai u co o ac tnh cao, phat trien nhanh, di can theo ng mau en phoi,
tuy xng va co the cho di can hach. (Hnh 38)
Hnh 38: Sarcom c van nam sau trong phan mem ui, mat cat mau o, co o xuat huyet va hoai t(A);
Vi the te bao u giong nguyen bao c van, nhan tang sac, bao tng ai toan, co cha van c (B,C,D).
VI. U MACH MAU (tumors of blood vesels)

Gom co u mach mau lanh (hemangioma) va sarcom mach mau (angiosarcoma), a c
trnh bay trong chng benh ly tim va mach mau.
VII. U CO HNG BIET HOA KHONG RO RET (Tumors of Uncertain Differentiation)

La 1 nhom gom nhieu loai u phan mem khac nhau, co the lanh tnh, giap bien ac hoac
ac tnh. U co hnh anh vi the ac trng nhng hng biet hoa lai khong ro rang, th du sarcom
mang khp.
Sarcom mang khp (Synovial sarcoma):
La 1 u phan mem khong ro hng biet hoa, v tuy co ten goi la sarcom mang khp
nhng khong co bang chng cho thay te bao u biet hoa theo hng mang khp. U xay ra
ngi tre t 15 40 tuoi, thng thay phan mem gan khp; kch thc t 3 - 5 cm, gii han ro
nhng khong co vo bao, mat cat trang, co vung thoai hoa boc. Cau tao vi the ac trng gom 2
pha vi nhng te bao u hnh thoi, xep thanh bo, nam chen gia cac cau truc gia tuyen, cung do
te bao u tao nen. U co o ac tnh cao, co the cho di can theo ng mau en phoi va di can
hach. (Hnh 39)
Hnh 39: Sarcom mang khp nam trong khoi c quanh xng chay va xng mac (*), u gii han ro, mat cat
trang, co vung thoai hoa boc (A); te bao u hnh thoi xep bo (1), chen gia cac cau truc dang tuyen (2, B).
VIII. SARCOM KHONG BIET HOA / KHONG XAC NH LOAI (Undifferentiated/

Unclassified sarcoma)
La nhom u mi c a vao trong bang phan loai u phan mem 2013 cua To chc Y te
the gii, nhng lai chiem t 10 en 20% sarcom phan mem. U khong cho thay 1 hng biet hoa
nao ro ret e xep vao trong cac nhom phan loai a co; en mc ma thay thuoc giai phau benh
anh phai s dung hnh dang te bao u e at ten cho chan oan, th du nh sarcom khong biet
hoa te bao hnh thoi, sarcom khong biet hoa te bao tron, sarcom khong biet hoa te bao dang
bieu mo, sarcom khong biet hoa te bao a dang... ang chu y nhat la loai sau cung, bi no
cung la loai sarcom phan mem thng gap nhat.
Sarcom khong biet hoa te bao a dang ( Undifferentiated pleomorphic sarcoma)

La loai sarcom phan mem thng gap nhat ngi tren 50 tuoi. U thng nam sau trong
phan mem chi di hoac trong vung sau phuc mac; kch thc 5 - 10 cm, gii han ro nhng
khong co vo bao, mat cat mau trang xam, co nhng vung hoai t xuat huyet. Tren vi the, cac te
bao u hnh thoi hoac a dien, nhan a dang va d dang, t le phan bao cao va co nhieu phan bao
bat thng, co the thay cac te bao khong lo nhieu nhan. Sarcom khong biet hoa a dang co o
ac tnh cao, u ln nhanh, xam nhap tai cho va cho di can xa en phoi va gan, 1 so trng hp co
the cho di can hach; t le song con 5 nam sau ieu tr ch vao khoang 50%. (Hnh 40)
Hnh 40: Sarcom khong biet hoa a dang, nam sau, gii han ro, khong vo bao, mat cat nhieu o hoai t va
xuat huyet, gay loet da be mat (mui ten, A). Te bao u hnh thoi, nhan a dang va d dang, phan bao bat
thng (mui ten), co te bao khong lo nhieu nhan (B)..

1. ac iem cua benh mem xng:
A/ Chat dang xng khong c khoang hoa ay u
B/ Be xng mong i
C/ Hay gap tre em
D/ a sun tiep hp phnh to
E/ Chan bien dang cong vong
2. Tren vi the, cac be xng cua vung xng xop b mong i, phan bo tha tht, ri rac. Vo xng
ac cung khong con day nh trc, la hnh anh cua benh nao sau ay:
A/ Benh loang xng B/ Benh mem xng C/ Benh coi xng
D/ Benh viem xng si hoa boc E/ D tat bam sinh
3. KHONG PHAI ac iem cua viem xng tuy xng sinh mu
A/ Xay ra tre em nhieu hn ngi ln B/ a so do vi khuan gram am gay ra
B/ Gay hoai t xng hoa mu D/ Tao ra cac manh xng tu
E/ Co the do mu ra da
4. ac iem cua benh coi xng tre em la:
A/ Gay xng t phat B/ a sun tiep hp phnh to C/ Bien dang bo xng
D/ A & B ung E/ B & C ung
5. Benh thoai hoa khp:
A/ La tnh trang viem khp xng man tnh B/ Thng gap tre em
C/ Hay xay ra cac khp chu tai nang
D/ Sun tiep hp b bong troc, e lo ban xng di sun
E/ ieu tr hieu qua bang thuoc khang viem
6. Tnh trang bien dang va cng khp trong benh viem khp dang thap la do:
A/ Sun khp thoai hoa B/ Tran dch khp C/ Tang sinh mang khp
D/ Mang si hoa si va hoa voi E/ Viem khp
7. Mot phu n 63 tuoi b gay co xng ui sau mot cu nga nhe; nhieu kha nang nhat la do:
A/ Viem xng tuy xng man tnh B/ Thieu vitamin D
C/ Loang xng hau man kinh D/ U tuyen can giap lanh tnh
E/ Benh a u tuy
8. Tren vi the can si la :
A/ Khoi mau tu B/ Mo hat viem C/ Mo si D/ Mo sun E/ Mo sun si
9. V tr thng gap cua sarcom xng la:
A/ Vung hanh xng B/ Gan goi xa khuyu C/ au xng
D/ A, B ung E/ A , C ung
10. Mot thieu nien nam 15 tuoi, b tai nan giao thong lam au chan phai, nghi gay xng. Chup X
quang phat hien mot o can quang kem, gii han ro khoang 2cm vung hanh xng au di
xng ui phai. Chan oan nao co nhieu kha nang phu hp nhat:
A/ U xng dang xng B/ U lanh sun C/ Sarcom xng
D/ Sarcom sun E/ U ai bao xng
11. Yeu to quan trong e chan oan sarcom xng:
A/ Chat dang xng c tao trc tiep t te bao u
B/ Te bao u d dang ac tnh C/ Phan bao bat thng
D/ Cac manh xng chet E/ Phan bao nhieu
12. Benh nhan nam 30 tuoi, b sng au goi trai hn 1 thang; X-quang cho thay co 1 vung huy
xng gii han ro ng knh 7cm au di xng ui; sinh thiet thay co 2 loai te bao, te bao
n nhan va ai bao nhieu nhan. Chan oan phu hp nhat cho tnh trang nay la:
A/ U xng dang xng B/ Sarcom xng B/ U ai bao xng
D/ Sarcom sun E/ Lao xng
13. Tren X quang co hnh anh huy xng tao xng, tam giac Codman va tia loe mat tri gap
trong loai u nao:
A/ U lanh sun B/ Sarcom sun C/ Sarcom xng
D/ U ai bao xng E/ U xng dang xng
14. Mot phu n 60 tuoi c mo sinh thiet 1 khoi u nam sau vung ui phai, gii han ro, kch
thc 8cm, chac. Tren vi the u gom cac te bao u hnh thoi giong nguyen bao si, xep thanh bo
bat cheo nhau nh xng ca, t le phan bao cao. U nay c chan oan la:
A/ Sarcom si B/ Sarcom c van C/ Sarcom c trn
D/ Sarcom m E/ U ac mo bao si
15. Sarcom c van:
A/ U phan mem ac tnh hay gap nhat tre em B/ Tren vi the co nguyen bao c van
C/ U co o ac tnh thap
D/ A va B ung E/ B va C ung
16. U phan mem:
A/ La u xuat phat t cac te bao trung mo a biet hoa co san trong phan mem
B/ Loai lanh tnh chiem a so C/ Loai ac tnh hiem khi cho di can hach
D/ Ch A va B ung E/ Ch B va C ung
17. U ac phan mem thng gap nhat tuoi trung nien :
A/ Sarcom si B/ Sarcom khong biet hoa a dang C/ Sarcom m
D/ Sarcom mach mau E/ Sarcom c trn
Tai lieu tham khao 365
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367
PHU LUC 1:
IEU KIEN THI, CACH THI, CACH TNH IEM, THANG IEM
NOI DUNG:
Hoc phan Giai phau benh gom 2 phan:
- Ly thuyet: 46 tiet.
- Thc tap: 14 buoi, moi buoi 2 tiet. Quan sat tong cong 44 tieu ban.
Hoc vien khong c d thi het mon thc tap neu vang t 3 buoi tr len.
CACH THI:
- Thi ly thuyet: 100 cau trac nghiem. iem tnh tren 10.
- Thi thc tap: 40 cau quan sat vi the (chay ban). iem tnh tren 10.
CACH TNH IEM:
iem hoc phan Giai phau benh c tnh nh sau:
- Ly thuyet co he so 3, thc tap co he so 2; lay iem trung bnh cong (TBC).
- Ly thuyet hoac thc tap < 5 nhng 4:
* Neu TBC 5 : at yeu cau mon hoc.
* Neu TBC < 5 : Thi lai phan ly thuyet hoac thc tap < 5.
- Ly thuyet hoac thc tap < 4: Phai thi lai phan ly thuyet hoac thc tap < 4 cho du TBC 5.
- iem TBC sau 2 lan thi se da tren iem ly thuyet va thc tap cao nhat a at c.
- Hoc vien khong c d thi (vang 3 buoi) hoac vang mat trong ky thi khong ly do c
tnh iem 0 cho iem lan 1. (Giay xin phep hoan thi hp le phai c gi en Bo mon trc
ngay thi).
THANG IEM
Ly thuyet Thc tap
So cau ung iem So cau ung iem
1-5 0 1 0
6-11 0.5 2-3 0.5
12-17 1 4-5 1
18-23 1.5 6-7 1.5
24-29 2 8-9 2
30-35 2.5 10-11 2.5
36-41 3 12-13 3
42-47 3.5 14-15 3.5
48-53 4 16-17 4
54-59 4.5 18-19 4.5
60-63 5 20-21 5
64-67 5.5 22-23 5.5
68-71 6 24-25 6
72-75 6.5 26-27 6.5
76-79 7 28-29 7
80-83 7.5 30-31 7.5
84-87 8 32-33 8
88-91 8.5 34-35 8.5
92-94 9 36-37 9
95-97 9.5 38-39 9.5
98-100 10 40 10

BG giải phẩu bệnh Y phạm ngọc thạch

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BG giải phẩu bệnh Y phạm ngọc thạch

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Chu nhiem bo mon : Gs.Ts.Bs.

NGUYEN SAO TRUNG

PHAN I: GIAI PHAU BENH AI CNG

Chng 1 GII THIEU VE MON HOC GIAI PHAU BENH 1

PHAN II: GIAI PHAU BENH CHUYEN BIET

Chng 6 BENH LY HE TIM MACH 111

PHAN III: TAI LIEU THAM KHAO 365

GII THIEU VE MON HOC GIAI PHAU BENH

oi dong ve lch s phat trien mon giai phau benh

Triet gia Aristote (384-322 Tr CN), co tinh

en au the ky I, mot hoc gia La ma ten

Hnh 8: G.B.Morgagni va cuon sach Ve v tr va nguyen nhan

Hnh 9: Giao s K.Rokitansky va J.Skoda

en Julius Cohnheim (1839-1884), la ngi a co cac nghien cu sau ve phan ng viem va la

Trong thi ai cua Virchow, cac thay thuoc van cha

T gia the ky XX, nghien cu benh tat a tien sang

Hnh 13: Phim khoa hoc vien tng Gattaca (1997)

I. NH NGHA VA PHAN LOAI GIAI PHAU BENH HOC:

III. PHNG PHAP NGHIEN CU CUA GIAI PHAU BENH

* Mien dch men:

3. oi chieu lam sang - giai phau benh

TON THNG C BAN CUA TE BAO VA MO

CAC AP NG THCH NGHI

2. TANG SAN (hyperplasia)

a/ Tang san sinh ly:

4. CHUYEN SAN (metaplasia)

5. NGHCH SAN (dysplasia)

ONG NOI BAO (intracellular accumulation)

a/ ong triglycerid ( ong m):

LANG ONG NGOAI BAO

1. LANG ONG CHOLESTEROL

2. LANG ONG PROTEIN

3. LANG ONG CALCI

S CHET TE BAO (Cell death)

1. AC IEM HNH THAI:

b/ Bien oi bao tng:

c/ Bien oi mang te bao:

Hnh 23: C che gay hoai t te bao

B. T HUY TE BAO (apoptosis):

2. NGUYEN NHAN VA C CHE GAY T HUY TE BAO

Hinh 27: Hai con ng t huy te bao

C. CAC HNH THAI MO HOC CUA HOAI T

b/ Hoai t hoa long (liquefactive necrosis):

c/ Hoai t m (fat necrosis):

d/ Hoai t ba au (caseous necrosis):

e/ Hoai t hoai th (gangrenous necrosis):

Hnh 32: Hoai th kho (A); Hoai th t (B)

MOT SO CAU HOI T LNG GIA

1. T cung cua mot phu n mang thai to ra la nh te bao c trn t cung:

5. S calci hoa mang x va ong mach:

6. KHONG PHAI la ac iem hnh thai cua te bao hoai t :

7. T huy te bao co ac iem:

10. KHONG PHAI la hien tng chuyen san:

VIEM CAP TNH

Hnh 1: O viem cap tnh ngon tay cai do vet can

Hnh 3: Tieu tnh mach gian rong cha ay hong cau

2. Phu viem (inflammatory edema)

Hnh 5: Te bao noi mo co lai, e lo ra cac khoang h

Hnh 6: Mo ke long leo ay dch xuat

S hnh thanh phu viem co cac tac ong tch cc nh:

3. S tham nhap te bao

- Tu vach (margination & adherence):

Hien tng tu vach xay ra do 2 c che sau: