Bnh hc ung th ph qun phi

i cng

Ung th ph qun phi nguyn pht (UTPQPNP) hin nay c tn sut ang tng
ln mt cch ng s.
L nguyn nhn gy t vong do ung th hng u nam v hng th 4 n. Bnh
nguyn ch yu l thuc l.
Pht hin thng mun nn iu tr kh v vy tin lng lun lun nng.
Nguyn nhn v yu t nguy c
Gii: Ung th ph qun phi gp nam nhiu hn n vi t l 6/1.
Tui: Bnh gp ti a nam khong 65 tui v n khong 75 tui.
Mi trng: Bnh thng gp cc thnh ph ln gp 3 ln so vi nng thn.
Thuc l:
Khi thuc l c xc nh 1 cch chc chn l nguyn nhn gy ung th ph
qun phi. 90% ung th ph qun phi l do thuc l. T l ung th ph qun phi
tng theo s iu thuc ht trong ngy v s nm nghin ht. Nu ht trn 20
gi/nm th t l ny tng r rt.
Khi thuc l lm chm s thanh lc nhy lng lm tn thng nhng chc nng
thc bo ca b my h hp.
Nhng enzyme ca nim mc ph qun khng thch ng vi s tn cng ny: bin
cc cht trong khi thuc l thnh cht gy ung th.
Cai thuc l lm gim nguy c nhng khng lm mt nguy c.
nhim mi trng khng kh chung:
Khi k ngh, khi xe hi cha benzopyrene v mt s cht c nh hydrocabure
a vng, cht khc nh kim loi, cht phng x.
nhim mi trng ngh nghip:
Bi thch min, bi m hay cc cht trong k ngh nh chrome, niken, arsenic,
mc in sn phm k ngh du m, cc cht phng x.
Khi thuc l c tc dng hp lc gy ung th.
Mt s yu t khc:
So phi c th lm d ung th dng tuyn hn cc th khc.
Phn loi
Phn loi theo gii phu bnh
Theo OMS ung th ph qun phi c phn thnh nhng loi sau:
Ung th dng biu b.
Ung th t bo nh khng bit ho.
Ung th dng tuyn:
Ung th tuyn nang bit ho cao.
Ung th tiu ph qun ph nang.
Ung th tuyn t bit ho.
Ung th t bo ln khng bit ho.
Ung th phi hp dng biu b v tuyn.
Ung th carcinoide.
Ung th tuyn ph qun.
Ung th nh ca biu b b mt.
Ung th hn hp carcinosarcome.
Sarcomes.
Khng xp loi.
Ung th trung biu m (ung th mng phi).
U mlanine.
Trong 4 loi u l thng gp.
Phn giai on ung th phi theo TNM (theo hip hi M trn h thng ung th)
U tin pht:
To: Khng thy u
Tx: U ch pht hin sm bng t bo ung th trong cht tit ph qun. TIS: ung th
biu m ti ch
T1: U c d 3cm, soi ph qun khng thy lan n ph qun thu.
T2: Uc d>3 cm hay u khng k kch thc hoc lan n mng phi tng hoc c
xp phi hoc c vim phi nghn, c lan n ph qun thy hay cch ca ph
qun 2cm. Xp phi/vim phi nghn ch 1 phi
T3: U khng k kch thc xm ln thnh ngc hay c honh hay mng phi trung
tht hay mng ngoi tim (m khng tn thng tim, mch mu ln, kh qun, thc
qun, ct sng).
Hoc u trong ph qun gc cch ca ph qun < 2cm.
T4: U khng k kch thc xm ln trung tht hay tim hay mch mu ln, kh
qun, thc qun, ct sng, ca ph qun.
Hoc trn dch mng phi.
Tn thng hch:
No: Khng c di cn n hch.
N1: Di cn n hch quanh ph qun hay rn phi.
N2: Di cn hch trung tht cng bn v cnh ca ph qun.
N3: Di cn hch trung tht khc bn, hch rn phi khc bn, hch c thang hay
thng n cng hay khc bn.
Di cn xa:
Mo:khng di cn xa.
M1: Di cn xa nh thng thn, gan, xng, no.
Bng: Phn theo TNM.
Giai on T N M
Ung th biu m Tx No Mo
n
Giai on 0 TIS No Mo
Giai on I T1 No Mo
T2 No Mo
Giai on II T1 N1 Mo
T2 N1 Mo
Giai don IIIa T3 N1 Mo
T1-3 N2 Mo
Giai on IIIb Bt k T N3 Mo
T4 Bt k N Mo
Giai on IV Bt k T Bt k N M1
Triu chng lm sng
Biu hin trong lng ngc
Ho:
Ho thng tng ln v tn s v trm trng.
Ho ra mu:
Lng nhiu hay t, chim t l 50% trng hp.
Vim ph qun phi do nghn:
U pht trin trong lng ph qun gy nghn ph qun khng hon ton lm ri lon
thanh thi nhy lng, gy tr, t d dng b vim ph qun phi thu phi
tng ng.
Vim ph qun phi do nghn c c im: vim phi khu tr, p ng chm hay
khng hon ton vi khng sinh thch hp, vim phi lp i lp li cng mt v tr.
Ting rt khu tr:
Ran wheezing gi nghn khu tr khng hon ton.
Xp phi:
Khi c hi chng xp phi l khi ph qun b hp hon ton.
Trn dch mng phi:
C th l trn dch thanh t huyt hay trn mu, c th do u lan trc tip hay do di
cn, c khi do phn ng ca xp phi.
au ngc:
au c nh v dai dng chng t ung th di cn n thnh ngc, mng phi hay
trung tht.
Hch ln:
Hch c th rn phi, trung tht, c thang, c th din tin m thm hay gy chn
p, n mn cc ph qun, cc mch mu hay cc m ri thn kinh ln cn.
Biu hin chn p, tc nghn do u, do di cn, do hch vng:
Tnh mch ch trn trong trung tht b chn p lm c ln ra, sau ph o khoc,
tm mt, gin tnh mch di da vai, ngc.
Thn kinh qut ngc tri b chn p, gy khn ging, lit dy thanh m tri (dy
thanh m phi c vng cao quanh ng mch di n nn t b chn p).
Thn kinh honh: Cc dy thn kinh ny i dc theo trung tht trc mi bn, mt
trong hai c th b chn p, gy lit na c honh tng ng, ch pht hin nh ri
phi, thy c honh di ng ngc chiu.
Hi chng Pancoast Tobias:
Ung th nh phi xm ln mng phi nh chn p cc r di ca m ri thn
kinh cnh tay, thn kinh giao cm c. Hi chng gm au vai, au cnh tay km
hi chng CLAUDE BERNARD HORNER cng bn (ng t co, sp m, hp khe
mt) c khi n mn xng n.
Biu hin ngoi lng ngc (di cn)
3 c quan hay b di cn nht l:
H xng gy au xng, au tri lc nm ngh, ti pht vi cc thuc gim au
thng dng.
H thn kinh trung ng: t l u phi di cn ln no rt cao, gy lit cc dy thn
kinh s no, lit na ngi.
Gan.
Cc di cn khc nh mng bng, thng thn, thn, ng tiu ho.
Hi chng h thng
Cc hi chng ny bin mt khi ung th c ct b v ti pht khi di cn pht
trin.
Tng calci mu:
Tng calci mu do parathormone bt thng v mt cht gy tan xng khc
parathormone.
Tng calci mu gy bun nn, nn, tiu nhiu, l ln ng lm, sng s.
Hi chng tit ADH bt thng:
Gy h natri mu, gim p lc keo, tng t trng nc tiu, nc tiu cha nhiu
natri.
Hi chng CUSHING:
Ung th ph qun phi tit ra cht lng t nh ACTH, thng t hot ng hn
ACTH tht.
Hi chng carcinoide:
Cn xung huyt da, ph mt, tng tit nc mt, tng tit nc bt, tiu chy nn,
h huyt p do 5 hydroxytryptamine (serotonine) v 5 hydroxytryptophane c
tit ra trong u carcinoide hoc ung th t bo nh khng bit ho.
V ln:
Ung th t bo ln tit ra khch thch t sinh dc gy v ln.

Ri lon thn kinh c:

C ch cha r, hi chng ny khng bin mt khi ung th c ct b.
Thng gp l: Hi chng nhc c, thoi ho tiu no, c khi c no v tu, hi
chng thn kinh ngoi bin.
Ngn tay di trng:
Hi chng PIERRE MARIE (hi chng xng khp ph i do phi):
Xng khp ca cc chi i xng au, sng ko di. X quang thy vim v tng
sinh mng xng, thng gp u xng chy v xng mc, km ngn tay
chn di trng. Bin mt khi ung th c ct b.
Gim min dch t bo khng c hiu:
Phn ng b lao (+) l mt yu t tin lng tt sng st sau m gp i phn ng
b lao (-).
Triu chng cn lm sng
X quang
Ung th dng biu b v ung th t bo nh khng bit ho thng rn hay gn
rn, ung th dng tuyn v ung th t bo ln thng xa rn trong ch m.
Ung th dng biu b thng di dng khi m trn b khng u, khng ng
cht, mt bn, c th hng ha, d gy vim phi do nghn hay xp phi.
Ung th t bo nh khng bit ho thng di dng khi m, t ng cht, b
khng u, c xu hng lan ra xung quanh.
Ung th dang tuyn thng di dng khi trn, u, m, b r.
Ung th tiu ph qun ph nang thng di dng khi trn n c hoc nt
thm nhim lan rng mt hay hai phi.
Ung th t bo ln thng di dng khi trn, m, b kh r.
Cc tn thng ung th thng khng bao gi b calci ho.
Chp ct ln t trng
Gip xc nh chnh xc cc tnh cht ca khi m bt thng trong nhu m phi,
v trung tht, gip sinh thit di s hng dn ca CT SCANNER chn
on m hc.
Soi ph qun
Soi ph qun bng ng soi mm gip chn on trc tip v thm d s lan rng
ca ung th bng cch chi ra ph qun v sinh thit tn thng hay sinh thit c
h thng cc ph qun.
T bo hc
Kho st t bo trong m cho kt qu dng tnh trn 70%, dng tnh gi t, pht
hin c t bo ung th ngay khi hnh nh x.quang bnh thng. Do t bo hc
trong m l mt xt nghim sng lc nhm c nguy c.
Sinh thit hch
Hch ngoi vi d dng c sinh thit, sinh thit hch trung tht c tin hnh
phng m do bc s chuyn khoa lm.
Chc ht xuyn thnh bng kim nh
p dng cho nhng ung th ngoi bin, kh soi ph qun. C th chc di s
theo di trn mng hunh quang. D gy trn khi mng phi.
Sinh thit mng phi
Sinh thit mng phi phi tin hnh mi trng ngoi khoa. C th kho st t
bo hc dch mng phi.
M thm d
bnh nhn c ch nh m. Sinh thit v xt nghim gii phu bnh tc th v
quyt nh m tip tc hay khng.
Thm d di cn
Phi lm siu m v chp ct lp t trng mi kt lun c mt cch cht chn.
Thm d chc nng h hp
Ch yu l xt ch nh m v thm d kh nng phi lnh.
Nu VEMS 1/2 bnh thng v paCO2 bnh thng 40 3 mmHg th khng cn
thm d thm.
Cht ch im ung th
Ch xc nh c l c khi u, gip theo di din tin sau iu tr.
Chn on phn bit
Lao phi
Chn on kh khn trong nhng trng hp sau: BK m m tnh v khng tm
thy t bo ung th trong m trong 3 ngy lin, trn phim X.quang c khi m
hnh trn, ng knh 2-3 cm b r hoc mt m m. Gp cc trng hp ny
nn iu tr th lao mt cch tch cc, ng thi tm mi cch pht hin t bo ung
th. Sau mt thng chm nht l hai thng nu hnh nh trn phim r nt hn l
ung th.
Vim phi
Sau mt thi gian iu tr vim phi, nu sc kho khng tr li bnh thng, cc
tn thng trn phim X.quang khng xo ht, lng mu vn cao... cn ngh n
ung th ph qun phi.
iu tr
V mt iu tr ngi ta chia ung th ph qun phi ra lm 2 nhm chnh.
Ung th khng phi ung th t bo nh khng bit ho
C thi gian nhn i 100-200 ngy, gm 3 loi: ung th dng biu b, ung th
dng tuyn, ung th t bo ln.
Phu thut l phng php hu hiu nht, p dng cho cc giai on ung th n,
giai on 1 v giai on 2 v mt s trng hp chn lc nh T3, No, Mo hay T1,
N2, Mo.
Kt qu:
Ung th n: Sng st sau 5 nm khong 60%. Theo di k v d b ti pht khong
5%/nm/ngi.
Ung th nt n c: M ct b thu phi. Tin lng tu theo kch thc khi u,
theo hch vng v theo s bit ho ca t bo k.
Sng st sau 5 nm khong 40-60% nu kch thc < 3cm v khng c hch vng.
Sng st sau 5 nm khong 20% n < 40% nu kch thc > 3cm v c hch
vng.
Khng phu thut c dng a ho tr liu v x tr liu nu khng c chng ch
nh.
X tr liu kt qu khng tt lm, i khi khng hn bnh nhn khng c x tr
liu.
a ho tr liu:
Bng: Kt qu mt s a ho tr liu.
c im Paclitaxel Gemcitabin Paclitaxel
/carboplati e /Gemcitabin
n /carboplatin e
S bnh nhn 308 309 312
Thi gian 7,9 thng 7,6 thng 8,4 thng
sng st
trung bnh
Sng st 1 33% 31% 33%
nm
Bng: T l sng st sau 5 nm.
Tc gi v S Nhm thuc sng st 5
nm cng b bnh nhn iu tr nm %
Arriagada et 1867 Cisplatin v 44,5
al-2004 hoc
Etoposide
Vinorelbine
Vindesine
Vinblastine
Winton et al- 482 Cisplatin- 69
2004 Vinorelbine
Strauss et al- 344 Carboplatin- 71(4 nm)
2004 Paclitaxel
Rosell et al- 840 Cisplatin 51
2005 -Vinorelbine
Ung th t bo nh khng bit ho
y l loi ung th pht trin nhanh, di cn sm v nhiu ngay khi bnh c v khu
tr, do mi c gng ct b u v hiu, nn a ho tr liu v x tr liu l chnh.
Ho tr liu:
Thuc c ch topoisomerase I bao gm irinotecan v topotecan. Phi hp
irinotecan hay topotecan vi ciplastin cho kt qu tt, tuy nhin c mt s tc gi
phi hp etoposide vi cisplatin hay vi carboplatin
X tr:
X tr c dng trc hoc sau ho tr liu bi bc s chuyn khoa.
iu tr triu chng v iu tr h tr cho c hai loi:
Chng au, chng nhim khun, gim ho.
Chng chn p thn kinh: dexamethasone 20-80 mg /ngy.
Ht dch mng phi.
Chng suy tu, chng thiu mu.
Phng bnh
Tuyn truyn tc hi ca thuc l trn cc phng tin truyn thng i chng
vn ng mi ngi b thuc l
Chng nhim mi trng trong nh, mi trng ngh nghip.