Ung Thu Hoc

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Chng I
I CNG V UNG TH
I. NH NGHA
Trong thi i ngy nay mc d khoa hc c nhng tin b vt bc c bit l trong
lnh vc sinh hc phn t, tuy nhin nh ngha bnh ung th l g vn khng d dng.
Tuy nhin chng ta c th nh ngha ung th nh l qu trnh bnh l trong mt s t
bo thot ra khi s kim sot, s bit ha sinh l ca t bo v tip tc nhn ln. Nhng t bo
ny c kh nng xm ln v ph hy cc t chc chung quanh. ng thi chng di tr v n
pht trin nhiu c quan khc nhau v hnh thnh nn di cn, ui cng ung th gy t vong do:
- Cc bin chng cp tnh nh: xut huyt t, chn p no, ngt th.
- Tin trin nng dn tin n ri lon chc nng ca cc c quan do khi di cn nh
thiu nng h hp, suy chc nng gan thn.
- S thoi trin dn dn, ko di dn n suy kit v cui cng bnh nhn t vong.
II. QU TRNH TIN TRIN T NHIN CA UNG TH
Mi loi ung th u c s tin trin khc nhau, tuy nhin nu ung th khng c iu
tr th s din bin qua cc giai on sau:
1. Giai on khi u
1.1. Bc khi u
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Thng xy ra rt nhanh, sau khi cc t bo tip xc vi cc tc nhn gy ung th: tc
nhn vt l, tc nhn ha hc, tc nhn virus. Cc tc nhn ny gy ra thng tn DNA ca t
bo khng hi phc.
1.2. Giai on thc y
Do tip xc lin tc, ko di vi cc cht gy ung th lm n nh v duy tr thng tn
u tin.
Bc khi u v giai on thc y chng ta ch bit c qua m hnh th nghim v
nhng nghin cu v dch t ung th ngi.
1.3. Giai on tin trin
Cc t bo nhn ln khng kim sot c, pht trin c lp, mt kh nng bit ha, xm
ln cc b v cho di cn.
Hnh 1: S giai on khi u

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d phng giai on khi u sinh ung th ngi ta phi bo v trnh tip xc vi cc
tc nhn gy ung th nh thuc l, benzol, nhiu loi ha cht khc nhau, tia phng x, virus v.v.
2. Ung th tin trin
S tin trin ca bnh ung th gii thch c bn cht ca bnh ung th l g: khi u pht
trin cc b ti ch, xm ln ti vng v cho di cn ton thn.
Khi tin trin ung th xy ra, c nhiu bin php chng li s tin trin :
+ Sng lc v iu tr cc thng tn tin ung th.
+ Sng lc v iu tr nhng ung th kch thc cn nh (ch yu bng phu thut
hoc tia x).
+ iu tr tch cc cc ung th ang cn ti ch (thng kt hp vi iu tr h tr
ha tr liu hoc ni tit tr liu).
Hnh 2: Cc giai on tin trin ca ung th

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3. Ung th di cn
Di cn ung th l tnh trng cc t bo ung th tch ri ra khi u nguyn pht n c
tr v pht trin thnh khi u c quan khc qua cc ng khc nhau: ng bch huyt, ng
mu, ng k cn.v.v.
Di cn theo ng bch huyt
+ Loi ung th biu m thng di cn n cc trm hch bch huyt khu vc. Khi
khi u tin n thnh bch huyt, t bo ung th xm ln nhanh chng qua thnh bch huyt v
c h thng lu thng bch huyt mang ti trm hch u tin. Khi cc t bo ung th i n
hch ngi ta nhn thy phn ng c hiu gi l vim bch mch mn tnh c hiu (specific
chronic lymphadenitis).
[1] T bo ung th ri khi u tin pht chy dc theo mch bch huyt
hng v hch v tinh
[2] Hch phn ng tiu dit t bo ung th
[3] T bo ung th li trong hch khng c phn ng
[4] T bo ung th chy qua hch v tinh m khng c phn ng c hiu
[5] T bo ung th pht trin v xm nhp hch bch huyt
[6] T bo ung th ph v v v xm ln t chc chung quanh
[7] T bo ung th lan n hch k cn
[8] Tc gy ph n bch mch

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1. Khi cc t bo ung th bong ra khi khi u, chng tri dc theo dng chy ca h thng bch
huyt n hch v tinh.
2. Phn ng ca h bch huyt c th tiu dit cc t bo ung th.
3. T bo ung th li trong hch bch huyt m khng c phn ng g, gi l di cn vi th.
4. i khi t bo ung th i qua hch v tinh m khng c phn ng c hiu no
5. Ngc li t bo ung th nhn ln, xm nhp ton b hch bch huyt, to ra hnh nh u c
hiu (hch cng, khng au, c nh).
6. Hch c nh l do t bo ung th ph v bao v xm ln ti cc t chc chung quanh.
7. Cc t bo ung th c th di tr ti hch k cn to ra hin tng vim h bch huyt dng
ung th (carcinomatous lymphangitis).
8. Nhng thng tn trn hnh 8 gii thch tnh trng bch huyt v ph bch huyt.
S hin din ca di cn bch huyt trn mu bnh phm phu thut, hoc s xm ln hch
bch huyt l c hiu ca ung th ang tin trin. Tin lng thng ngho nn v cc nh ung
th hc phi tnh n iu tr kt hp x tr, ha tr, ni tit, min dch sau phu thut.
Di cn theo ng mu:
+ Cc loi ung th ca t chc lin kt (ung th xng, ung th phn mm)
thng di cn theo ng mu n cc tng xa nh gan, phi, no.

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Hnh 5: Ung th di cn theo ng mu
Di cn theo ng k cn:
+ Di cn hay i dc theo mch mu v thn kinh, theo li t b cn tr, in hnh l
ung th d dy lan qua lp thanh mc vo bng gy di cn bung trng.
+ Dao m, dng c phu thut c th gy gieo rc t bo ung th ra ni khc trong
phu thut nu m trc tip vo khi u.
III. D PHNG UNG TH
Mc du c nhng tin b rt ln trong lnh vc iu tr ung th trong hai thp k qua,
nhng ung th vn cn l mt bnh kh c th iu tr khi.
Tuy vy khong 50% trng hp bnh ung th c th phng trnh c. D phng ung
th l mt vai tr mi rt quan trng i vi tt c cc thy thuc trong th k 21. ch ng

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phng chng ung th, thy thuc phi tnh n kha cnh lun l v t do c nhn, cc chnh
sch phng chng tch cc phi da vo c s kin thc khoa hc.
1. Vai tr ca thuc l
Ngi ta chng minh c thuc l gy ra nhiu loi ung th:
+ Bng cc nghin cu v dch t hc.
+ Bng nhng nghin cu v thnh phn cha trong thuc l.
+ Bng s khm ph ra s thng tn gen c hiu ca t bo khi u v t bo
bnh thng nhng ngi ht thuc.
+ Bng s pht trin nhng kin thc c bn v s chuyn ha ca amines ca
thuc l.
Qua nghin cu dch t hc v sinh hc c s lin quan r rt gia thuc l v cc ung th
sau y:
+ Phi
+ Thanh qun
+ Khoang ming
+ Vm mi hng
+ Bng quang
Nghin cu v thnh phn cha trong thuc l ngi ta tm thy hn 4000 loi ha
cht, mt s ha cht chnh gy ra ung th:
+ Polycyclic aromatic hydrocarbons
+ Nitrosamines
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+ Heterocyclic hydrocarbons
+ Benzen
+ Radioactive 210-polonium
Tt c nhng ha cht c trn c th gy ra s khi u v thc y qu trnh sinh ung
th. Phng php d phng tch cc nht l khng nn ht thuc l i vi nhng ngi cha
ht c bit l tr em, vi nhng ngi ht phi c hnh thc h tr ngi ht thuc t b
thuc l v cc bin php nhm gim thiu tc hi ca thuc l nh cm ht thuc ni cng
cng, in hnh logo ln bao thuc.v.v.
2. Yu t di truyn
T vn v di truyn: l mt phng php mi trong iu tr ung th. Ngi ta phi xem
xt nhiu kha cnh khc nhau c thi x l ng n. Mc ch ca thm khm di truyn
trong ung th l:
+ nh gi nguy c di truyn ca ung th vi mc ch xc nh c hay khng c
di truyn.
+ a ra nhng chnh sch sng lc ph hp vi nguy c ung th .
+ Khi c ch nh c th thc hin nghin cu phn t v gen di truyn.
+ Gii quyt yu t tm l lo lng ca bnh nhn v nguy c di truyn.
+ C k hoch theo di thi gian di cho c nhn v gia nh ca h.
3. Ho d phng trong ung th
Ngi ta nhn thy rng mt s loi thuc gip d phng ung th:
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+ S dng Tamoxifen (anti-estrogen) d phng ung th v trng hp c nguy c
cao v yu t gia nh. Nghin cu ln Hoa k cho kt qu tt.
(NSABP Breast cancer prevention trial P-1)
+ S dng mt s loi thuc khng oestrogen khc (raloxifen) phng long
xng nhng ph n mn kinh gip d phng ung th ni mc t cung (ASCO 2005).
+ S dng cc thuc khng androgen (finasteride) d phng ung th tin lit
tuyn.
+ S dng cc thuc khng vim non-steroid d phng ung th i trng.
IV. SNG LC UNG TH
Mc ch ca sng lc ung th l pht hin nhng trng hp ung th cha c biu
hin lm sng bng cch s dng cc test chn on hoc cc phng php khc c th p dung
c rng ri trong cng ng. Kt qu ca sng lc thng phn thnh 2 nhm: 1 nhm khng
pht hin ung th v v nhm kia c nhng biu hin nghi ng cn c nhng xt nghim chuyn
khoa chn on xc nh.
Mt phng php sng lc c hiu qu phi chng minh c s gim t l t vong
nhng bnh nhn c sng lc so vi nhng bnh nhn khng c sng lc.
Loi ung th l tng chn sng lc l:
+ Loi ung th c t l t vong cao trong cng ng
+ C mt thi k tin lm sng rt di
+ Pht hin c giai on sm, iu tr c hiu qu

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+ Pht hin c bng cch s dng test c nhy v c hiu cao, gi c xt
nghim va phi v t gy c hi cho c th c th lm lp li nhiu ln.
Trong thc t hin nay ch c mt s t loi ung th c li ch thc s khi thc hin sng
lc: ung th v, ung th c t cung, ung th da, ung th i trc trng, ung th tin lit tuyn
mc du vn cn mt s tranh ci v mt s k thut thc hin.
Li ch m sng lc ung th mang li bao gm:
+ Ci thin c tin lng cho bnh nhn nh vo pht hin sm qua sng lc
+ Gim thiu cc phu thut ct b rng ri lm mt chc nng.
+ Lm yn lng nhng ngi c test sng lc m tnh.
+ Lm gim chi ph trong iu tr ung th.
+ Cui cng tt nhin lm gim t l t vong thng qua chnh sch sng lc.
V. CHN ON UNG TH
Mi v tr ung th c cc triu chng pht hin khc nhau, tuy nhin mi triu chng pht
hin u xut pht t sinh l bnh hc, c bit l s pht trin c trng ca mi loi khi u.
Khi cc triu chng xut hin r, thy thuc nn thc hin mt s th tc chn on:
+ Thc hin chn on cng sm cng tt, thm khm v thc hin cc th thut
trnh gy au n, lo u cho bnh nhn.
+ Nhanh chng sinh thit khi u c chn on xc nh v gii phu bnh.
+ Yu cu kim tra v lm sng v cn lm sng nh gi ung th ang tin
trin ti ch hay di cn xa.
+ Chn on chnh xc giai on bnh.

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+ Kim tra li chn on nhanh v chnh xc quyt nh phng php iu tr
thch hp nht. Chn on chm dn n iu tr chm v bnh nhn mt i c hi iu tr khi
bnh, kt qu iu tr cng xu i.
VI. XP GIAI ON BNH TRONG UNG TH
Xp giai on bnh trong ung th c nhiu mc ch:
+ D on c tin lng ca bnh.
+ Ch nh iu tr ph hp vi giai on bnh.
+ So snh kt qu iu tr gia cc nhm bnh nhn tng i ng nht.
+ Nghin cu kt qu iu tr theo giai on bnh
Thy thuc phi thc hin chn on bnh v chn on giai on trc khi ra bt k
phng php iu tr no, mc ch chung l:
+ Trnh nhng s iu tr khng cn thit. V d :Thc hin phu thut khi bnh
nhn c di cn.
+ a ra phng php iu tr thch hp hn
Xp giai on da ch yu vo cc d kin v lm sng v cn lm sng. Nhng yu t
chnh cn c xp loi nh sau:
+ Mc ca xm ln khi u ti ch
+ Mc di cn xa
+ Loi gii phu bnh ca ung th vi nh gi bit ha ca loi ung th .
+ C th s dng nhiu loi cht ch im khi u.

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+ Trong mt tng lai gn cc cht ch im v gen v nhng bt thng khc v
proten c th tr thnh cc yu t xp giai on.
+ Cui cng l tnh trng ton thn ca bnh nhn.
VII. CC PHNG PHP IU TR UNG TH HIN NAY
1. iu tr phu thut
Trong mt thi gian di phu thut c xem l phng php duy nht iu tr ung th
v n nay n vn cn c xem l hn tng trong iu tr ung th hin i.
Nhng tin b vt bc trong k thut m, trong gy m hi sc hon thin kt qu
ca phu thut.
Theo mt s tc gi Timothy.J.Eberlein, Jonh M.Daly th ngy nay 60% n 75% cc
bnh nhn ung th c iu tr bng phu thut v cc k thut ngoi khoa cn c s dng
chn on, xp hng cho hn 90% cc bnh ung th. Khong chng 1/2 bnh nhn ung th
giai on m c c th p dng phu thut trit cn. Phu thut c th phi hp vi cc
phng php iu tr khc nh x tr, ha tr, ni tit, min dch v.v.
Nhng nguyn tc chung trong phu thut ung th:
+ Phi tho lun phng php iu tr a m thc trc khi phu thut (thng l
hi chn vi cc bc s x tr v ha tr).
+ Tng trnh r rng bin bn phu thut
Cc u im ca phu thut ung th:
+ Cc loi u c tnh khng c s khng sinh hc i vi k thut ngoi khoa.
+ Phu thut khng c tc dng c tim nng sinh ung th.

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+ Phu thut c kh nng iu tr mt s ln ung th giai on ti ch v ti
vng.
+ Phu thut cho php nh gi mc xm ln ca khi u cng nh xc nh c
tnh m hc ca khi u lm c s cho xp loi v ch nh iu tr.
Cc nhc im ca phu thut ung th:
+ Phu thut c th c cc bin chng e da n tnh mng bnh nhn hoc
lm mt chc nng sinh l mt s c quan. Bc s phu thut cn cn nhc mc rng ca phu
thut trnh tn thng nhng c quan quan trng v l mt trong nhng nguyn nhn tht
bi ca phu thut.
+ Nhng tn thng c tnh vt qua giai on ti ch v ti vng th vai tr
ca phu thut khng cn ph hp.
Cc loi phu thut gm
+ Phu thut chn on
+ Phu thut trit cn
+ Phu thut gii hn
V d : Phu thut ct mt phn v.
+ Phu thut lm gim th tch khi u
+ Phu thut thm st
+ Phu thut ti pht v di cn
+ Phu thut triu chng
+ Phu thut ti to
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+ Phu thut gim au
2. iu tr tia x
iu tr tia x l s dng tia bc x ion ha iu tr ung th, l phng php iu tr
th 2 sau phu thut c p dng hn 100 nm nay.
Chng ta phn bit 2 loi iu tr tia x:
+ Tia x ngoi : Ngun phng x nm ngoi c th gm cc my iu tr tia x
nh cobalt, gia tc
Ngi ta phi thc hin m phng bnh nhn trc khi x tr. S dng mt my Xquang
c bit c tt c tnh nng ca mt my x tr, tr ngun phng x c thay bng u n pht
tia X gip xc nh khu vc s c chiu x (trng chiu) trn ngi bnh nhn, gip cho vic
iu tr c chnh xc hn.
Trong thi i ngy nay iu tr tia x c nhng tin b vt bc c bit,cc quang t
v m in t nng lng cao ngy c s dng nhiu hn, k thut tnh liu v iu tr ngy
cng tinh vi hn. Vi s pht trin cc kin thc su v vt l phng x, sinh hc phng x cng
vi vic pht trin h thng vi tnh trong lp k hoch iu tr lm cho iu tr tia x chnh xc
hn, hiu qu iu tr c tng ln ng k gp phn cha khi hn 50% s ca ung th mi
c chn on.
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Hnh 6. iu tr bng my x ngoi
+ Tia x p st: Ngun phng x c t trong c th bnh nhn. Cc ng v
phng x c s dng l cc ngun mm c th un nn c nh Cesium 137, Iridium 192
hoc Radium226. Ngui ta chia ra 2 loi:
Ngun phng x kn bao gm:
+ X tr p st k (interstitial brachytherapy) ngun phng x t trong khi u
+ X tr p st cc hc (endocavitary brachytherapy): ngun phng x t trong
cc hc t nhin ni khi u ang pht trin.
X tr p st t s dng n thun ngoi tr mt s ung th giai on rt sm, thng
thng l phi hp vi tia x ngoi v cc phng php iu tr khc.

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Hnh 7: iu tr bng my x trong
+ Ngun phng x dng lng: Cht phng x c tim trc tip vo bnh nhn
i vi mt s ung th c bit: I131, P32, St 189.
3. iu tr ho cht
T khi bt u tin trin, ung th c th cho di cn, do cc phng php iu tr ti
ch v ti vng nh phu thut v x tr thng khng mang li hiu qu. S dng cc thuc iu
tr ung th c bit l cc ha cht chng ung th c th ngn chn c tin trin ca ung th.
Ha cht chng ung th u l nhng cht gy c t bo. iu tr ha cht da trn s p ng
khc bit nhau gia t bo ung th v t bo lnh. c trng tng trng ca ung th c nh
hng rt ln n p ng vi ha tr. Cc hiu bit v ng hc t bo, s tng trng ca khi
u, sinh hc ung th l cn bn cho cc nguyn tc ha tr lm sng.
3.1. Cc ch nh ca ha tr ung th:
Ha tr gy p ng (induction chemotherapy) p dng i vi cc loi ung th giai
on mun.
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Ha tr h tr (adjuvant chemotherapy) sau khi iu tr phu thut, tia x cc ung th
ang cn ti ch v ti vng.
Ha tr tn h tr (neoadjuvant chemotherapy) ha tr c thc hin trc khi iu tr ti
ch v ti vng.
Ha tr ti ch: nhm mc ch lm tng nng thuc ti khi u bng cch bm thuc
vo cc xoang, hc ca c th hoc bm thuc trc tip vo ng mch nui khi u.
Ch nh iu tr ha tr cn da vo nhiu yu t nh giai oi bnh, loi bnh hc, tui
ca bnh nhn, cc phng php c iu tr trc , th trng bnh nhn xc nh ch
nh c th ca ha tr. Phi lun lun cn nhc mt bn l li ch ca ha tr v mt bn l c
tnh v nhng nguy him c th xy ra.
Bn cnh kh nng c th iu tr khi mt s ung th, ha tr c th gip lm gim thiu
mt s triu chng lin quan n ung th v t lm tng cht lng cuc sng v ko di thi
gian sng thm cho bnh nhn ung th.
4. Cc phng php iu tr khc
Ngoi cc phng php iu tr chnh nu trn cn nhiu phng php iu tr khc c
nghin cu trong nhng nm gn y.
4.1. iu tr min dch: c 2 loi chnh
Min dch th ng khng c hiu: Interferon v interleukin
Min dch ch ng khng c hiu: Bm BCG vo trong bng quang

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4.2. iu tr ung th hng ch (Targeted cancer therapy)
iu tr ung th hng ch l s dng cc loi thuc ngn chn s pht trin v lan rng
ca t bo ung th bng cch cn tr cc phn t c hiu lin quan n qu trnh sinh ung th v
s pht trin ca khi u. Bi v cc nh khoa hc gi cc phn t ny l phn t ch (moleculer
targets), nn cc phng php iu tr ngn cn chng gi l iu tr hng ch phn t
(moleculerly target therapies). iu tr nhm vo ch phn t l phng php iu tr c hiu
qu hn cc phng php iu tr hin nay v t gy c t bo hn.
Hu ht cc trng hp iu tr ung th hng ch l cc th nghim tin lm sng, mt
s ang trong giai on th nghim lm sng v mt s khc c FDA ng a vo iu
tr. iu tr ung th hng ch c th s dng n thun hoc kt hp vi nhau hoc kt hp vi
cc phng php iu tr khc nh ha tr liu.
iu tr ung th hng ch bao gm nhiu loi thuc, mt s c lit k di y:
+ Thuc tc ng cc phn t nh (small molecule) ngn cn nhng enzyms c
hiu v GFRs (Growth Factor receptor) lin quan n s pht trin t bo ung th. Nhng thuc
ny cng cn c gi l thuc c ch dn truyn tn hiu.
+ Gleevec: (STI-571 hoc imatinib mesilate) l loi thuc tc ng vo cc phn
t nh c FDA cho php s dng iu tr ung th t bo m ca ng tiu ha (mt loi ung
th him gp ca ng tiu ha) v mt vi loi bnh bch cu ty mn.
+ Iressa: (ZD1839 hoc gefinitib) c FDA chp thun trong iu tr ung th
phi khng phi t bo nh. Thuc ny tc ng vo yu t th th pht trin biu b (epidermal
growth factor receptor), yu t ny c to ra qu nhiu bi nhiu loi t bo ung th. Nhng

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loi thuc tc ng vo cc phn t nh khc ang c nghin cu th nghim lm sng ti Hoa
K.
Thuc gy ra cht t bo theo lp trnh : (Apoptosis-inducing drugs) lm cho cc t bo
ung th tri qua cht theo lp trnh (t bo cht do ngn cn nhng protein lin quan trong qu
trnh):
+ Velcade (bortezomib): c FDA chp thun iu tr a u ty khng p
ng vi cc phng php iu tr khc. Velcade gy ra cht t bo ung th bng cch ngn cn
enzyme gi l proteasome, enzyme ny gip iu ha chc nng v s pht trin t bo.
+ Genasense (oblimersen) l thuc gy cht t bo theo lp trnh, c nghin cu
iu tr leukemia, non-Hodgkin lymphoma, cc khi u c. Genasence ngn cn s sn xut ra
mt protein gi l BCL-2, protein ny thc y s tn ti ca t bo khi u. Bng cch ngn cn
BCL-2, Genasence lm cho t bo ung th d tn thng hn vi cc thuc chng ung th.
Khng th n dng, cc vaccin chng ung th, cht c ch tng sinh mch v iu tr
ung th bng gen (gen therapy) c xem l cc phng php iu tr hng ch bi v chng
ngn cn s pht trin ca t bo ung th.
+ Trastuzumab (Herceptin)
+ Rituximab (Mabthera, Ritusan)
+ Alemtuzumab (Mabcampath, campath)
+ Cetuximab (Erbitux)
+ Erlotinib (Tarceva)
iu tr chng tng sinh mch:

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+ Bevacizumab (Avastin)
+ Thalidomide
iu tr chng proteasome:
+ Bortezomibe
Cng ngy cng c nhiu loi thuc mi khc c nghin cu v p dng vo iu tr.
VIII. TIN LNG BNH
Tin lng bnh ung th ph thuc vo nhiu yu t, mt s yu t chnh dng nh
gi tin lng sau y:
+ Giai on bnh: Bnh giai on sm tin lng tt, nu c iu tr
kp thi c may khi bnh cao. Tri li bnh giai on mun iu tr ch ko di thi gian sng
thm v gim nh triu chng cho ngi bnh.
+ C quan b ung th: C nhng loi ung th tin lng tt l loi ung th d pht
hin giai on sm, tin trin chm nh ung th da, ung th gip trng, ung th c t cung, ung
th v, ung th khoang ming, ung th i trc trng.
Ngc li cc loi ung th ca cc tng quan trng kh pht hin sm, kh iu tr, tin
trin nhanh nh ung th phi, ung th gan, ung th no, ung th xng.v.v.tin lng xu.
+ Tnh cht c tnh ca t bo ung th: T bo ung th c c tnh thp tin lng
tt. Tri li c tnh cng cao tin lng cng xu.
+ Th trng ngi bnh: ngi bnh cng gi ung th tin trin chm li nhng th
trng yu khng th thc hin iu tr trit c nn tin lng xu.

21
CU HI KIM TRA NH GI
1. Nu cc giai on tin trin ca bnh ung th ?
2. Nu cc phng php iu tr bnh ung th hin nay ?
3. Cc yu t gip tin lng bnh ung th ?
TI LIU THAM KHO
I. TI LIU TING VIT
1. i hc Y H Ni, 1999. Bi ging ung th hc, NXB Y hc , H Ni.
2. L nh Roanh, 2000. Bnh hc cc khi u, NXB Y hc, H Ni, trang 5-9.
3. Nguyn Chn Hng v CS, 1986. Din bin t nhin ca bnh ung th. Trong: Ung th hc
lm sng, tp I, ti bn ln th nht, Trng i hc Y Dc Tp HCM, trang 79-112.
4. UICC, 1995. Ung th hc lm sng, NXB Y hc, H Ni, trang 22-44.
II. TI LIU TING ANH
1. Alani R.M and Munger, 1998. Human Papilloma Viruses and Associated Malignancies. J clin
Oncol; 16: 330-337.
2. Chambers AF, Hill RP, 1998. Tumor Progression and Metastasis in: The Basic Scinece of
Oncology 3rd editon. The MacGrawHill.; chaper 10, 219-239

1
Chng II
DCH T HC UNG TH
Mc tiu hc tp
1. Trnh by c cc khi nim thng dng trong dch t hc ung th
2. M t c s thay i ca dch t bnh ung th v s lin quan ca cc yu t nhn khu n
t l mi mc.
3. Hiu qu trnh ghi nhn ung th trn th gii v ti Vit Nam
I. I CNG
Dch t hc l mn hc nghin cu v s phn b v nhng yu t lin quan n bnh tt
trong mt qun th dn c. Dch t hc cung cp nhng thng tin c gi tr v cc m hnh v
nguyn nhn sinh bnh.
Ti cc nc pht trin, cng vi s gia tng tui th trung bnh th bnh ung th l
nguyn nhn gy t vong th hai sau bnh tim mch. Hin nay, nhiu quc gia ang pht trin,
t l ung th ghi nhn c thp hn nhiu, hu ht do t l t vong cao hn v cc bnh nhim
trng v chn thng. Vi s gia tng kim sot St rt v Lao mt s nc ang pht trin, t
l ung th c trng i s tng ln.
Dch t hc ung th phn nh st s phn b yu t nguy c cc nc khc nhau.
Cc loi ung th thng gp tnh chung c 2 gii nam v n, c tnh hng nm trn ton
cu cho thy khong 10,9 triu ca ung th mi mc v khong 6,7 triu ngi cht vi ung th
(2002)
2
Thng k cho thy cc bnh ung th thng gp trn th gii l:
- Ung th phi: lun chim t l cao nht c cc nc pht trin v ang pht
trin ( khong 13,5% ), bnh c mi lin quan cht ch vi thuc l.
- Ung th v: chim t l 11,5%, l bnh ung th hng u ph n
- Ung th i trng: chim t l 10,2%, lin quan n ch n nhiu cht bo v
t rau qu.
- Ung th d dy: 9,34%, nguyn nhn chnh do vi khun Helicobacter Pylori, c
mi lin quan cht ch vi cc thc n p mui nh: cc loi da mui, tht mui, tht hun
khi
- Ung th gan nguyn pht:chim t l 6,26%, hai nguyn nhn thng gp l
bnh vim gan siu vi ( HBV, HCV) hoc n cc loi ng cc nhim nm Aspergillus
- Ung th tin lit tuyn: thng gp ngi cao tui, l bnh ung th nam gii
hng u ti cc nc pht trin, chim t l 6,79%
- Ung th c t cung: chim t l 4,93%, HPV c coi l th phm hng u cho
bnh ung th ny ( 82% )
Ti VN, hng nm c khong 100.000-150.000 trng hp mi mc ung th v khong
70.000 ngi cht do ung th.
VN, qua nghin cu TPHCM v H Ni cho thy 10 loi ung th thng gp

3
Bng 1: Cc bnh ung th thng gp 2 gii
TH T Nam N
1 Gan C t cung
2 Phi V
3 D dy i trc trng
4 i trc trng Phi
5 Tin lit tuyn D dy
6 Hc ming Gan
7 Vm hu Bung trng
8 Thc qun Tuyn gip
9 Lymphm Thn t cung
10 Bnh bch cu Bnh bch cu
II. MT S KHI NIM TRONG DCH T HC UNG TH
1. Xut (Incidence)
c tnh bng s ca ung th mi xut hin trong mt qun th dn c, thng c tnh
theo s ca ung th mi mc mi nm trn 100.000 dn. y l ch s tt nht ca tn sut mc
bnh ung th.
Ngi ta c lng tng s ca ung th mi mc trn th gii nh sau:
Nm 2002: 10,9 triu (vi 24,6 triu ngi sng chung vi ung th )
Nm 2020: 16 triu ( vi 30 triu ngi sng chung vi ung th )

4
T l mi mc thng c dng cung cp nhng d liu v s xut hin ung th trong
qun th dn c theo nhm tui, gii tnh, chng tc...ngi ta c th tnh t l mi mc cho ton
b dn c hoc tng b phn ca qun th dn c vi nhng c trng phn b khc nhau.
2. T sut (Mortality)
S ca t vong trn 100.000 dn mi nm.
Tnh hnh t vong do ung th: cc nh dch t hc ghi nhn nm 2002, trn th gii c
6,7 triu ca t vong do ung th, l nguyn nhn gy t vong th hai cc nc pht trin sau
bnh tim mch v ng th ba cc nc ang pht trin sau bnh nhim trng v bnh tim
mch.
T l t vong do ung th ngy cng cao ph thuc vo hai nguyn nhn chnh:
- Yu t nhn chng hc: tui th ca con ngi ngy cng tng m s ung th
hay gp nhng ngi c tui.
- Kh nng v chn on tin b hn nh m nhiu loi ung th c chn
on trc lc cht.
Tuy nhin, nhiu nc, cc thng k chnh thc cha cng b mi loi t vong.
3. T l mc bnh ton b (Prevalence)
L con s c tnh ton b s ngi mc bnh ung th ( tt c cc v tr ung th hay gp
li mt v tr no ) v nhng ngi ny sng ti mt thi im nht nh hoc mt thi im
nht nh trong khong thi gian xc nh, thng tnh bng s ca ung th trn 100.000 dn
Ch s ny dng nh gi gnh nng v bnh tt ca cng ng.
Tng theo t l mi mc v khong thi gian trung bnh m bnh ko di.

5
III. S THAY I DCH T HC UNG TH
1. Xu hng gim
Xu hng gim ung th c t cung mt phn do s p dng rng ri xt nghim t bo c
t cung, iu tr cc thng tn tin ung th tng cng cc iu kin v sinh cho ph n, sinh
c k hoch v t l ct t cung ton b tng ln cng vi s pht hin vacxin d phng ung th
c t cung.
S gim i ca ung th d dy lin quan n s ci thin v sinh dinh dng, iu tr c
hiu qu vi khun Helicobacter Pylori cng nh n nhiu thc n cha cc cht chng oxy ho.
S gim i ca bnh u lympho c tnh, ung th tinh hon, i trng do s ci thin ca
cht lng iu tr
2. S tng thm
S gia tng ca ung th phi, ung th bang quang c quy kt do tng tiu th thuc l.
Xu hng tng thm ca ung th v v ung th tin lit tuyn l do tui th ca con
ngi ngy cng tng.
Tng ln ca ung th da do thi quen tm nng.
IV. S DAO NG CA T L MI MC THEO CC YU T NHN KHU
1. Tui
L yu t quan trng nht xc nh nguy c mc bnh ung th. i vi hu ht ung th
loi t bo biu m th t l mi mc tng r rt theo tui.
Mi quan h gia tui v t l mi mc biu th hiu qu tch ly qua qu trnh tip xc
vi cc tc nhn sinh ung th theo thi gian.

6
Tuy nhin, khng phi bao gi cng quan st c hin tng ny.
- T l mi mc ca bnh bch cu lympho c nh cao tui 3-4.
- i vi ung th v, s gia tng chm dn sau tui mn kinh v t l mi mc ung
th c t cung rt thp sau 50 tui.
Khi so snh t l mi mc ca cc bnh ung th gia cc quc gia i hi t l ny phi
c chun ha theo mt qun th dn c thun nht v cu trc tui ca cc nc rt khc nhau,
dn s chun c s dng rng ri nht l dn s th gii. y l mt qun th dn c gi nh
c cu trc tui nm gia qun th gi ca cc nc pht trin v qun th tr ca cc
nc ang pht trin.
2. Gii
Nam gii c t l mc ung th cao hn n gii i vi phn ln cc loi ung th ngoi tr
ung th tuyn v, ng mt, mt, i trng v tuyn nc bt. S khc bit ny thng c
quy kt do s khc bit v tnh mn cm m c ch cha gii thch c.
3. Chng tc
S khc bit v tnh hnh mc ung th ca cc chng tc khc nhau trong cng mt quc
gia cho thy tnh mn cm di truyn v cc yu t vn ha c nh hng ti nguy c ung th.
Phi hp cc nghin cu di c c th phn lp c vai tr ca tng loi yu t ny.
4. Tn gio
Nhng ngi theo mt tn gio no c nhng np sng c bit nh hng ti c
im bnh ung th nhm ngi ny.
V d: T l mc ung th v cao cc n tu. Ung th dng vt rt thp ngi Do Thi
do lut ct bao quy u lc cn tr.

7
5. Ngh nghip
Vin ung th quc gia v an ton ngh nghip Hoa K nm 1978 cng b rng 30%
bnh ung th c lin quan n mi trng lm vic, trong 4-8% trng hp ung th l do mi
trng cng nghip. Php, hng nm c thm 7000-8000 trng hp ung th mi mc do ngh
nghip.
Mi ngi nn thc hin ng quy tc bo h lao ng ca ngh mnh ang lm s hn
ch c nguy c mc ung th.
6. Hon cnh kinh t x hi
Gm nhiu yu t quan h tng h: nn gio dc, mc thu nhp, ch n ung, mi
trng sng v lm vic, cht lng cc dch v t vn v chm sc sc khocng cha chng
minh mt cch r rt cc ch s v hon cnh nh hng nhiu n nguy c mc bnh ung th.
7. Cc nghin cu trn cc qun th di c
Cho thy s kt hp vai tr ca cc yu t di truyn v mi trng i vi nguy c ung
th da vo vic so snh nguy c ung th ca nhm nhp c vi qun th gc v qun th ni
nhp c.
V. GHI NHN UNG TH
1. nh ngha
Ghi nhn ung th l qu trnh thu thp mt cch c h thng v lin tc s liu v tnh
hnh mc bnh cng nh c im cc loi ung th ghi nhn c nhm h tr trong vic nh
gi v kim sot gnh nng ung th trong cng ng.
Vic xc nh tnh hnh t vong do ung th trc ht phi c h thng thng k t vong
v s liu dn tc hc ng tin cy c th tnh ton c t l t vong. nhiu quc gia ang

8
pht trin, chng nhn t vong thng khng c chng nhn ca thy thuc v nguyn nhn t
vong.
2. Ghi nhn Ung th ti Vit Nam
2.1. Xut
Xut chun theo tui (ASR) ca tt c cc ung th ( ngoi tr ung th da ) l 144,94
cho nam v 102,91 cho n.
2.2. T sut
T sut chun theo tui ca tt c cc loi ung th ( ngoi tr ung th da ) l 115,76 cho
nam v 66,14 cho n.
2.3. Cc loi Ung th thng gp
Bng 2: 10 bnh ung th thng gp Nam gii
Tnh \ Thnh ph H Ni Tha Thin Hu H Ch Minh

(2001-2004) (2001-2004) (2003)
V tr ASR Rank ASR Rank ASR Rank
Phi 39,8 1 10,8 3 29,5 1
D dy 30,3 2 14,4 2 15,3 3
Gan 19,8 3 16,4 1 25,4 2
i trc trng 13,9 4 4,9 4 16,2 4
Thc qun 9,8 5 1,7 9 4,0 8
Mi hng 7,8 6 1,5 12 4,2 7
U lympho c 7,2 7 3,8 5

9
Bnh bch cu 4,7 8 2,4 8 4,6 6
Bng quang 3,5 9 3,0 7
Vm hng 3,2 10 0,0 22 4,8 5
Li 1,9 14 1,6 10
Khoang ming 2,3 12 3,7 6
M mm 2,0 14 2,9 7
Ty 1,2 18 1,3 14
Tin lit tuyn 2,7 12 1,0 16 2,8 10
Nhau thai 1,3 17 0,9 12
Dng vt 1,8 14 1,5 13
Da 3,0 9
Bng 3: 10 bnh ung th thng gp N gii

(2001-2004) (2001-2004) (2003)
V 29,7 1 12,2 1 19,4 1
D dy 15,0 2 7,3 2 5,5 6
Phi 10,5 3 3,6 4 12,4 3
i- trc trng 10,1 4 3,4 5 9,0 4
C t cung 9,5 4 5,0 3 16,5 2
Tuyn gip 5,6 5 1,6 10 3,8 8

10
Bung trng 4,7 6 2,1 9 3,8 7
Gan 4,5 7 3,4 6 6,0 5
U lympho c 4,0 8 1,4 12
Bnh bch cu 3,4 9 1,4 11 3,2 9
Mi hng 3,3 10 0,5 18
M mm 1,4 13 2,6 8
Da 2,6 10
CU HI KIM TRA NH GI
1. nh ngha xut , t sut, t l mc bnh ton b trong dch t hc ung th ?
2. Nu tnh hnh dch t ung thu trn th gii v ti Vit Nam ?
3. Nu tnh hnh ghi nhn Ung th ti Vit Nam ?
TI LIU THAM KHO
I. TI LIU TING VIT
1. Bi bo khoa hc:
1. Nguyn B c & Nguyn Chn Hng, 2002. Chng trnh phng chng ung th giai on
2002-2010, Ti liu tp hun ghi nhn ung th, B Y t v Bnh vin K.
2. Sch:
1. i hc Y Khoa H Ni - B mn ung bu, 1999. Bi ging ung th hc, NXB Y hc, H
Ni, trang 13-17.

11
2. Phm Thy Lin, 1999. Lm th no pht hin sm bnh ung th, NXB Nng.
II. TI LIU TING ANH
1. American Cancer Society. Cancer fct and figures 2003.
2. Jensen, O.M.Parkin, D.M. Maclennan, R. Muir, C.S and Skeet, R.G (eds), 1991. Cancer
Registration: Principles and methods. IARC Scientific Publication, Lyon.
3. Oxford Handbook of Oncology 2002, pages 3-11.
4. Vincent T.DeVita, 1997. Principles & Practice of Oncology, pages 196-216.

1
Chng III
C CH BNH SINH
& QU TRNH TIN TRIN T NHIN
CA BNH UNG TH
Mc tiu hc tp
1. Nm c bn cht bnh ung th v tnh cht ca t bo ung th.
2. Hiu c vai tr ca Gen sinh ung v Gen nn bu trong c ch sinh ung.
3. Nm c cc tin trnh sinh hc phn t v cc yu t lin quan n c ch sinh ung.
4. Bit qu trnh tin trin t nhin ca bnh ung th, ng dng trong vic p dng cc phng
php chn on & iu tr bnh ung th
I. I CNG
- Ung th xy ra do s t bin trong DNA, dn n t bo tng sinh v hn , v t
chc, khng tun theo cc c ch kim sot v pht trin c th.
- Tnh cht c trng ca t bo ung th:
+ Trnh c apoptosis (cht theo chng trnh)
+ Kh nng pht trin v hn (bt t)
+ T cung cp cc yu t pht trin
+ Khng nhy cm i vi cc yu t chng tng sinh
+ Tc phn bo gia tng
+ Thay i kh nng bit ha t bo
+ Khng c kh nng c ch tip xc

2
+ Kh nng xm ln m xung quanh
+ Kh nng di cn n ni xa
+ Kh nng tng sinh mch mu
-Vi nhng hiu bit v vai tr ca Gen sinh ung v Gen nn bu cng cc khm ph
mi v s sinh mch ( angiogenesis ), cht t bo theo lp trnh (apoptosis), s sa cha vn ling
di truyn c th gip chng ta c c nhng hiu bit v c ch sinh ung t lm c s cho
mt liu php mi: liu php nhm trng ch (targeted therapy).
II. GEN UNG BU
1. ng dn truyn tn hiu t bo
Cng vi s pht trin ca cng ngh sinh hc, vai tr ca tin gen sinh ung (proto-
oncogen) vi chc nng sinh l iu ha ng dn truyn tn hiu t bo nhn cc kch thch
cho s phn bo v cht theo lp trnh c hiu bit hon ton.
Da vo v tr trn ng dn truyn tn hiu t bo, ngi ta chia tin gen sinh ung lm 4 phn:
- Cc yu t tng trng (growth factors)
- Cc th th ca yu t tng trng
- Cc tn hiu dn truyn (signal transducers) (Cc Protein G t bo cht)
- Cc yu t sao chp nhn t bo (transcription factors)
Hnh 1: ng dn truyn tn hiu yu t tng trng.

3
Cc giai on ca s dn truyn tn hiu t bo
Cc yu t tng trng n gn vo cc th th c hiu trn b mt t bo. S gn kt
ny lm thay i dng ca th th v gy tc ng vo phn th th trong bo tng, do tn
hiu c hot ha xuyn qua mng t bo. Tn hiu ny lan truyn qua t bo cht n nhn v
gn vo im sao chp c bit ca DNA nh cc phn t trung gian gi l Protein G. Tn hiu
ny lm t bo thay i tnh trng tng sinh ca n, c th chuyn t tnh trng phn chia sang
ngh ngi hay cht qua c ch gy cht t bo theo lp trnh.
1.1. Yu t tng trng
Cc yu t tng trng l cc phn t ha hc c trong mu hay trn b mt t bo khc.
V d:
+ Yu t tng trng xut pht t tiu cu ( Platelet Derived Growth Factor:
PDGF ).
+ Yu t kch thch cm (Colony Stimulating Factor: M-CSF )
1.2. Th th yu t tng trng
- Cc th th bao gm 3 phn:
+ Phn ngoi mng t bo: to mt v tr khuych i ha hc ch gn vi cc
yu t tng trng c hiu.
+ Phn trong mng t bo
+ Phn bn trong bo tng: l mt phn t c chc nng hot ng thay i khi
phn ngoi mng t bo c gn vi yu t tng trng, thong thng l mt Tyrosin kinase.

4
- S t bin thng lm tng chc nng ca Tyrosin kinase, lm n gi tn hiu vo bo
tng lin tc ngay c khi khng c yu t tng trng gn vo phn ngoi mng t bo ca th
th, dn n vic t bo tng sinh c lp vi yu t tng trng ca n.
1.3. Cc Protein G t bo cht (Cc tn hiu dn truyn)
- Cc Protein G l mt loi oncoprotein chuyn t dng khng hot ng thnh hot ng
khi nhn tn hiu t phn trong bo tng ca th th yu t tng trng.
1.4. Cc yu t sao chp nhn t bo
Khi cc tn hiu t bo n gn vo v tr sao chp nhn t bo c hiu s lm thay i
trng thi kch thch phn chia t bo.
V d:
+ t bin ca tin gen sinh ung myc s gia tng kch thch phn chia t bo,
thng gp trong ung th tr em ( U nguyn bo thn kinh).
Liu php nhm trng ch ung th pht trin ng k qua s tin b v sinh hc ung
th, ngy cng hiu nhiu c ch dn truyn tn hiu iu ha t bo. T vic s dng khng th
n dng Trastuzumas (Herceptin) chng li phn ngoi t bo th th erbB2 c gi tr trong iu
tr ung th v di cn.
2. Cht t bo theo lp trinh
Cht t bo theo lp trnh l mt kiu cht t bo, l mt bin c ph thuc vo nng
lng c lp trnh (do gi l cht theo lp trnh). y l c ch quan trng trong iu ha
t nhin trong c th bnh thng duy tr cn bng gia t bo sinh ra v cht i. Ngoi ra, v
mt ung th th y l c hi sa cha thng tn DNA ca t bo hay loi b t bo b t
bin c tim nng sinh ung.

5
C ch iu ha cht t bo theo lp trnh rt phc tp vi s tham gia ca nhiu gen ngn
cn v thc y tin trnh ny: P53, Bcl2.
Cht t bo theo lp trnh v ung th: gia tng s lng t bo khng ph hp l mt trong
cc im mu cht ca qu trnh sinh ung. iu ny c th l do gia tng s tng sinh hay gim t
bo cht.
3. Yu t tng sinh mch
Ngi ta chng minh rng: cc bu c c kch thc 2 3mm vn trng thi ng
yn nu khng c mch mu nui, cc thng tn tin ung th din tin thnh ung th xm ln v
cc di cn xa l thuc vo s sinh mch.
C ch sinh mch trng lp trong s xm ln v di cn ca bu. Cc nh nghin cu
khuyn nn c s phi hp cc cht khng sinh mch vi ha tr qui c nhm em li tc dng
lm chm pht trin bu v ngn nga di cn xa.
4. C ch tng sinh dng t bo
Khi mt t bin xy ra gen tin sinh ung s to mt dng t bo c u th tng sinh v
sinh sn thnh mt clon t bo bu, khi u cho mt ung th.
C 3 kiu t bin lm tng sinh mt dng t bo:
+ T bo t bin lm mt th th yu t tng trng: gy mt c ch kim sot
ngc dn n sn xut nhiu yu t tng trng. S tng sinh ny t gii hn bi s chnh lch
ca s lng yu t tng trng v s lng t bo.
+ T bo t bin sinh ra qu nhiu th th yu t tng trng v tng nhy cm
vi kch thch tng trng. T bo ny v t bo th h sau ca n tng sinh nh l mt bu n
clon, nu ly i yu t tng trng s lm ngng s pht trin ca bu.

6
+ T bo t bin sinh ra qu nhiu yu t tng trng: t bo ny t nhy cm vi
chnh cc yu t tng trng ca n. T bo ny v th h sau ca n tng sinh nh mt bu n
clon c lp vi yu t bn ngoi, l mt bu c tnh r.
III. GEN NN BU
Gen nn bu c vai tr lm chm li s phn chia t bo, n hot ng cng vi h
thng sa cha AND cn thit cho vic duy tr tnh n nh ca vn ling di truyn
Gen nn bu th ln, c hai bn sao ca gen phi b t bin mi khng ngn cn
c s tng trng t bo b thng tn.
Khi gen nn bu b t bin, khim khuyt AND c th c di truyn qua t bo
mm v l nguyn nhn ca cc hi chng di truyn d b ung th
V d:
+ Mt s t bin gene BRCA1 v BRCA2 lin quan n tng nguy c ung th
v v ung th bung trng
+ Cc khi u ca cc c quan ni tit trong bnh a u tuyn ni tit (multiple
endocrine neoplasia - MEN th 1, 2a, 2b)
+ Hi chng Li-Fraumeni (sarcoma xng, ung th v, sarcoma m mm, u no)
do t bin ca p53
+ Hi chng Turcot (u no v polyp i trng)
+ Bnh polyp tuyn gia nh l mt t bin di truyn trong gene APC dn n
pht trin sm ung th i trng
+ U nguyn bo vng mc tr em l ung th di truyn

7
IV. C CH SINH UNG
Ung th c bn cht l s t bin khng sa cha c trong AND do s tc ng ca
cc yu t sinh ung ( ha hc, bc x, virus).
Khi u ca c ch sinh ung l s hot ha gen sinh ung v s t bin mt d hp t ca
gen nn bu. To s tng sinh u th ca mt dng t bo c tnh v pht trin bn vng
trong c th nh s tng sinh mch, chin thng h thng min dch ca c th ch c th xm
ln rng v di cn xa.
Hnh 2: S c ch sinh ung

8
V. CC GIAI ON TIN TRIN CA UNG TH.
1. Giai on khi pht
Bt u t t bo gc do tip xc vi cc tc nhn gy t bin, lm thay i khng phc
hi ca t bo.
Qu trnh din ra nhanh v hon tt trong mt vi giy v khng th o ngc c. Tuy
nhin ngi ta cha xc nh c ngng gy khi pht.
Trong cuc i mt con ngi th c nhiu t bo trong c th c th tri qua qu trnh
khi pht, nhng khng phi tt c cc t bo u pht sinh bnh. a s cc t bo khi pht hoc
l khng tin trin, hoc l cht i, hoc l b c ch min dch v hiu ha.
Hnh 3: Tc nhn t bin lm thay i khng hi phc DNA

9
2. Giai on tng trng, thc y, chuyn bin
y l cc giai on sau giao on khi pht; bao gm s chn lc dng t bo, s thay
i th hin gen, s tng sinh ca t bo khi pht. S tng sinh ca t bo ung th cn mc
nh, c tr mt m nh no .
3. Giai on lan trn
Tip theo cc giai on trn, ung th c th chuyn sang giai on lan trn. Giai on ny
c th ngn vi thng v cng c th ko di vi nm. giai on ny khi u bnh trng, gia
tng c th t 100 t bo n 1 triu t bo. Tuy nhin vn cn qu nh pht hin bng phng
php phn tch c.
Hnh 4: Khongcch thi gian gia ht thuc l v ung th phi

10
4. Giai on tin trin - xm ln- di cn
4.1. Giai on tin trin
c trng ca giai on ny l s tng ln ca kch thc khi u. ngi bnh thng s
lng t bo c to ra bng s t bo cht v lun gi mc hng nh (khong 1012 triu t
bo cht mi ngy v cn c thay th)
Khi b ung th, t bo sinh sn v hn dn n s ph v mc hng nh.
Trong giai on tin trin, chia ra hai giai on nh.
+ Giai on tin lm sng: y l giai on u, c th rt ngn vi thng nh u
lympho Burkit, cng c th ko di nhiu nm: Ung th trc trng, ung th phi, bng quang,
giai on ny c th ko di 15- 20 nm, c khi 40, 50 nm, chim 75% thi gian pht trin ca
bnh. Tuy cha c biu hin lm sng, nhng cng c th pht hin da vo cc xt nghim cn
lm sng.
+ Giai on lm sng: Trn lm sng ch pht hin khi khi u c kch thc trn
1cm3 (khong 1 t t bo), cn phi c 30 ln nhn i.
4.2. Giai on xm ln v di cn
4.2.1. Giai on xm ln
T chc ung th xm ln nh cc c tnh:
- Tnh di ng ca t bo ung th.
- Kh nng tiu m cc m k cn.
- Mt s c ch tip xc ca t bo.
11
4.2.2. Giai on di cn theo cc ng:
- Bch mch: gp nhiu trong ung th biu m. u tin c th lan trn theo ng bch
mch ti ch v i khi lm tc, ri lan n bch mch vng. Di cn thng t gn n xa, qua
cc trm hch, c khi nhy cc.
- Di cn theo ng k cn: cc t bo ung th i theo cc mch mu v thn kinh, theo
li t khi b cn tr nh: ung th d dy lan qua lp thanh mc vo bng, n bung trng...
- Theo ng mu: gp nhiu trong ung th lin kt. Khi i theo ng mu, t bo kt
thc mao mch v tng trng . Cc kiu lan trn theo ng mu:
+ Kiu phi ( kiu I ): T mt ung th ph qun-phi, cc t bo bu i qua tnh
mch phi, vo tim tri, ri vo i tun hon cho cc di cn khp ni ( gan, no, xng, thn,
thng thn)
+ Kiu gan ( kiu II ): T mt ung th gan, cc t bo c tnh i vo tnh mch trn
gan, tnh mch ch di, tim phi, ri vo phi to thnh cc di cn phi. Sau , cc t bo
ny c th i vo i tun hon v l ngun gc ca cc di cn kiu phi.
+ Kiu tnh mch ch ( kiu III ): T nhng ung th ca cc c quan khng dn
lu bi h thng ca nh: t cung, thn, cc t bo ung th i qua tnh mch ch, n thng
phi, ri sau i vo i tun hon nh di cn kiu I.
+ Kiu tnh mch ca ( kiu IV ): T cc ung th ca ng tiu ha, cc t bo c
tnh di chuyn n gan, cho di cn gan. T , n phi ( cho di cn kiu II ) ri vo i tun
hon ( cho di cn kiu I ).

12
CU HI KIM TRA NH GI
1. Bn cht v cc tnh cht c trng ca t bo ung th ?
2. Vai tr ca gen tin sinh ung trong ng dn truyn tn hiu t bo ? ng dng trong iu tr
bnh ung th ?
3. Cc kiu tng sinh dng t bo ?
4. C ch bnh sinh ca bnh ung th ?
5. Cc giai on ca qu trnh din tin t nhin bnh ung th ?
TI LIU THAM KHO
I. TI LIU TING VIT
1. H Y H Ni, 1999. Bi ging ung th hc, NXB Y hc, trang 17-28
2. L Dnh Roanh, 2001. Bnh hc cc khi u, NXB Y hc, trang 45-87
3. Nguyn Chn Hng v CS. 1986. Din bin t nhin ca bnh ung th, trong Ung th hc lm
sng, tp I, ti bn ln th nht, Trng i hc Y dc Tp HCM, trang 79-112.
4. UICC, 1995. Ung th hc lm sng, trang 1-45.
II. TI LIU TING ANH
1. Ellis L. M, Fidder I, 1996. J Angiogenesis and Metastasis Eur. J. Cancer; 32: 2451 2461.
2. Kastan MB, Skapek SX, 2001. Molecular biology of Cancer: The cell cycle in Cancer:
Principles and Practice of Oncology 7th edition J.B. Lippincott Co. Philadelphia, chapter 6, 91
109.
3. Krontiris, T. G 1995. Oncogenes N. Engl J. med. 333: 303 306.
4. Reed J.C, 1997. Dysregulation of Apoptosis in Cancer. J. clin Oncol 17: 2941-2953.
5. Reed J. C, 1999. Dysregulation of Apoptosis in Cancer. J. clin Oncol 17: 2941 2953.
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6. Sandal T, 2002. Molecular aspects of the mammalian cell cycle and cancer The oncologist, 7:
73 81.
7. Vincent T.De Vita, 2001. Principles & Practice of Oncology, pages 98-112.
8. Weiberg R. A, 2001. Cancer Biology and Therapy Road Ahead Cancer Biology &
Therapy:38
1
Chng IV
NGUYN NHN UNG TH
Mc tiu hc tp
1. K c cc nguyn nhn ph bin trong mi trng gy ung th.
2. Xc nh c nhng nguyn nhn c th d phng c cho nhng li khuyn b ch d phng ung th.
I. I CNG
Hin nay t l mc bnh ung th d bo ngy cng tng v kt qu cha khi bnh vn cn hn ch do a
s pht hin giai on mun. Mt s ung th ngay c giai on sm cng khng phi cha lnh bnh. V vy,
cch l tng nht l phi bit cch d phng ung th.
Nguyn nhn sinh ung th rt a dng, ngoi mt s tc nhn c bit r gy ung th nh thuc l,
amian.. vn cn nhiu nguyn nhn gy ung th ang c nghin cu.
Nghin cu nguyn nhn ung th khng ch da trn s hiu bit cc qu trnh sinh hc lin quan n bnh
tt m cn da vo bng chng dch t hc m t v phn tch bao gm s gii thch nhng khc bit quan st c
v tn sut ca mt s loi ung th theo gii tnh, tui tc, hon cnh kinh t x hi v a d.
Ngy nay nh nhng tin b vt bc ca khoa hc, c bit trong lnh vc sinh hc phn t ngi ta bit
r ung th do nhiu nguyn nhn sinh ra. Mt tc nhn sinh ung th c th gy ra mt s loi ung th v ngc li
mt loi ung th c th do nhiu nguyn nhn khc nhau. Hiu bit v cc yu t nguy c gy ung th gip d bo
nguy c mc ung th c cc bin php sng lc pht hin sm, gio dc v t vn sc khe. Nguyn nhn sinh
ung th gm 2 nhm chnh l cc yu t mi trng v tc nhn di truyn.
II. CC NGUYN NHN MI TRNG
Vai tr ca cc yu t sinh ung th ngi c trong mi trng c bit n cch y hn 200 nm
nh cc pht hin ca mt bc s ngi Anh tn l Percival Pott v s gia tng ung th da bu nhng ngi th
no ng khi vo nhng nm 1775. K t , cc bng chng v yu t mi trng gy ung th c ghi nhn

2
ngy cng nhiu. Ngy nay, ngi ta bit nhiu loi ung th gy ra do yu t mi trng bao gm cc tc nhn
vt l, ha hc, sinh hc. Chng tc ng t ngoi vo gy nn nhng t bin ca t bo v sinh ung th.
1.Tc nhn vt l
Ch yu l bc x ion ha v tia cc tm.
1.1. Bc x ion ha
Ngun tip xc tia phng x t nhin ch yu t cc cc tia v tr, t hoc cc vt liu xy dng. Ngun
tip xc phng x nhn to ch yu l trong chn on Y khoa. T l tt c ung th do tia phng x rt thp
(khong 2% - 3%).
Cc bng chng dch t hc:
+ Cc nh Xquang u tin khng t che chn nn thng b ung th da v bnh bch cu.
+ Ung th tuyn gip gia tng r nhng ngi iu tr tia x vo vng c lc cn tr.
+ Ngy nay ngi ta thy rng bnh phi cc th m vng Joachimstal (Tip Khc) v Schneeberg
(c) quan st c t th k 16, chnh l ung th phi do s hin din ca qung en c tnh phng x trong cc
m.
+ Nguy c ung th phi tng cao trong cc nghin cu v th m Uranium v th m cng di
lng t phi tip xc vi kh radon v l do ngh nghip.
+ Nghin cu nhng ngi sng st trong v n bom nguyn t Hiroshima v Nagasaki Nht
Bn nm 1945 cho thy tng nguy c nhiu loi ung th c bit ung th mu th ty cp.
+ 10 nm sau s c r r tia phng x Chernobyl 1986, ngi ta nhn thy t l ung th gia tng
mnh, trong c bit tr em b ung th tuyn gip tng gp 10 ln.
Qu trnh phng x bn ra cc ht lm ion ha cc thnh phn hu c ca t bo to ra cc gc t do.
Chnh cc gc t do ny tc ng ln cc base ca ADN lm ri lon cc gen t bo to ra cc bin d v t bin
gy ung th, qui thai v d tt.

3
Tc ng ca tia phng x gy ung th ngi ph thuc vo 3 yu t quan trng:
+ Tui tip xc cng nh cng nguy him nht l bo thai v tr nh.
+ Mi lin h liu p ng: phi nhim cng cao v cng ko di th nguy c cng tng.
+ C quan b chiu x: cc c quan nh tuyn gip, ty xng rt nhy cm vi tia x.
1.2. Bc x cc tm
Tia cc tm c trong nh sng mt tri gm 3 loi A, B v C gy bng da, ung th da, lot gic mc v c
thy tinh th. Cng gn xch o tia cc tm cng mnh. Tia C gy t bin mnh nht nhng c lc bi tng
ozon. Tia B kch thch cc t bo da to ra sc t melanin lm rm nng v da v tc ng trc tip ln ADN lm
lp da lo ha sm v t bo b bin i thnh ung th. Tia A do bc sng di nn t gy ung th da hn.
Cc bng chng dch t hc cho thy nhng ngi lm vic ngoi tri thng c t l ung th t bo y v t
bo vy ca da khu tr vng u, c cao hn nhng ngi lm vic trong nh. i vi nhng ngi da trng sng
vng nhit i t l ung th hc t cao hn hn ngi da mu.
Cn phi lu tro lu tm nng thi qu ca ngi da trng gy bng nng v tng nguy c ung th da.
Hin nay tng ozon ngy cng mng i do ngy cng c nhiu cht thi c hi t mt t, s phun ca ni la lm
hy hoi tng ozon lm tng c v cng ln bin tip xc vi tia cc tm. Kt qu d bo s gia tng tn
sut mi mc ca ung th da cng nh mt s bnh khc trong tng lai.
2. Tc nhn ha hc
2.1. Thuc l
Vai tr ca thuc l gy ung th c chng minh r rng bng:
+ Cc nghin cu dch t hc
+ Nghin cu cc thnh phn ca thuc l,
+ Pht hin cc tn thng di truyn c th cc t bo ung th v t bo bnh thng ngi ht
thuc l,
4
+ Hiu bit v s chuyn ha ca cc amine c trong thuc l.
Cc nghin cu dch t hc chng minh rng nhng ngi ht thuc l c nguy c mc cc ung th phi,
thanh qun, khoang ming, thc qun v bng quang. Nhng ung th ny t gp nhng ngi khng ht thuc l.
Quan st cng nhn thy mt s ung th khc cng ang gia tng nhng ngi ht thuc l: ung th ty, thn,
mi hng, d dy v ung th mu.
Thnh phn ca khi thuc l: C trn 4000 ha cht c trong khi thuc l trong 43 cht gy ung th
c nhn bit. Cc cht ny ch yu l:
+ Cc hydrocarbon thm a vng: c to ra t chy thuc l khng hon ton hay trong cc khi
v bi cng nghip
+ Nitrosamine: l cht gy ung th mnh nht ng vt th nghim v c vai tr ch yu trong ung
th phi, thc qun, ty, ming khi ht thuc.

5
+ Hydrocarbon d vng: c trong nha thuc l l nhng cht gy bin d mnh v sinh ung th
nhiu c quan khc nhau nh gan, phi
+ Benzene
+ Polonium-210 c hot tnh phng x
Trnh by u tin v mi lin quan gia ht thuc v tng t l ung th phi c bit n t mt nghin
cu ca-i chng c nm 1939. T ngi ta thc hin nhiu cuc nghin cu ca - i chng ca ht
thuc vi ung th phi tng gp 10 ln nhng ngi ht thuc so vi nhng ngi khng ht thuc.
V sau nh vo cc thng k ca Doll Anh ngi ta mi khng nh thuc l l nguyn nhn ca khong
90% ung th ph qun. Tnh chung thuc l gy ra khong 30% cc loi ung th ch yu l ung th ph qun v
mt s ung th vng mi hng, ung th ng tit niu. Ngoi cht Nicotin, trong khi thuc l cha rt nhiu cht
Hydrocarbon thm, trong cht 3-4 Benzopyren l cht gy ung th trn thc nghim. Tuy nhin c ch sinh ung
th ca thuc l cn c tip tc nghin cu.
Ngoi ra ht c xem l nguyn nhn ca nhiu bnh ph bin ngoi ung th nh bnh mch vnh, bnh
tt nghn phi mn tnh do thuc l...
Nhng bng chng gn y cho thy nguy c ung th phi gia tng nhng ngi khng ht thuc khi h
thng xuyn tip xc vi khi thuc thi ra t ngi ht thuc (v d khi thuc ca nhng ngi ht thuc trong
nh ).
2.2. Ch n ung v cc cht gy nhim thc phm
Ngi ta nhn thy c s khc nhau gia t l ung th ng tiu ha theo vng a l v theo thi quen n
ung. Nhng thay i nhanh chng v t l ung th d dy (gim) v t l ung th i trng (tng) th h ngi
Nht u tin di c sang M l bng chng r rng rng nhng thay i mi trng v ch n ung lm thay i
nguy c ca cc loi ung th ny.
Lm dng ru gy ung th: Lm dng ru l nguyn nhn lm tn hi sc kho ca nhn loi. Hng nm
ngi ta nhn thy khong 15-30% s bnh nhn nhp vin l do tc hi ca ru. Ung ru nhiu lm tng t l
6
ung th cao ch sau thuc l. Nghin ru lin quan n cc ung th vng ming, hng, thanh qun, thc qun v
gan. Cng tiu th nhiu ru th nguy c ung th cng cao v ngc li nguy c gim nu hn ch ung ru.
Cht bo v tht: Cc nghin cu cho thy vi ch n ung giu cht bo ng vt lm tng nguy c ung
th v v ung th i trc trng. cc nc pht trin, ni tiu th nhiu tht ngi ta thy t l ung th i trng
cao c ngha. Ngc li, ch n nhiu tri cy v rau xanh, qu chn v nhiu si thc vt cho thy lm gim
t l ung th i trc trng. T l mt s loi ung th khc nh ung th h hng thanh qun, thc qun, phi v v
cng gim nh.
Nhng cht gy nhim v cht ph gia trong thc phm: Tht c hong khi v p mui, cc loi mm v
da mui c rt nhiu mui Nitrat v Nitrit. Nitrat, Nitrit v Nitrosamin lm tng nguy c ung th thc qun v d
dy. Nitrosamin l cht gy ung th kh mnh trn thc nghim. Ngy nay cc nc giu nh cc tin b v bo
qun thc phm rau v thc phm ti sng bng cc hm lnh, gian hng lnh, t lnh lm gim cc thc phm
c cha mui Nitrat v Nitrit. T l ung th d dy cc nc ny cng gim xung r rt.
Thc phm mc gy ung th: Go, lc l hai loi thc phm d b mc. Nm mc Aspergillus flavus thng
c go, lc mc tit ra c t aflatoxin, cht ny gy ra ung th t bo gan nguyn pht. S t bin gen P53
c tm thy trong 53% cc trng hp ung th t bo gan nguyn pht cc khu vc c c t aflatoxin trong
thc phm.
Cc thc phm b nhim do thuc tr su c th gy cn bng pht ng c cp tnh. Tuy nhin ngy nay
ngi ta cha xc nh c mi lin h gia hin tng ny vi cc bnh ung th.
2.3. Cc ung th lin quan n ngh nghip
Theo cc nghin cu Php, phi nhim ngh nghip c th gy ra khong 3% t vong do ung th. Cc
nghin cu M nhng nm gn y c t l cao hn do phi nhim vi cc cht nh amian, arsen, nickel,
chrome, benzene v cc sn phm ca cng nghip ha du. Tuy nhin phi nhim ngh nghip l kh nh gi do
c s phi hp vi cc yu t khc nh thuc l v ru.

7
Tc nhn sinh ung quan trng nht trong vic gy bnh ung th ngh nghip ch yu l cc ha cht v t
gp hn l cc tc nhn khc nh vi rt, bc x ion ha. Vic nh gi ung th ngh nghip trong dn s ch mang
tnh cht tng i. Mt cng trnh nghin cu M cho thy rng 4% ung th c lin quan n ngh nghip. Mt
s nh gi ca cc quc gia cng nghip ha khc thy t l ny thay i t 2-8%... cc nc ang pht trin v
cc nc mi cng nghip ha t l ung th do ngh nghip cha c nh gi mt cch r rng. Cc ung th
ngh nghip thng xy ra cc h c quan tip xc trc tip vi cc nhn sinh ung th hay vi cc cht chuyn
ha cn hot tnh ca cc tc nhn ny.
Pott (1775) ln u tin m t t l ung th biu m da bu cao hn nhng ngi th co ng khi, ng
gi mi lin quan vi ngh nghip v cho rng m hng l nguyn nhn. Hc n v cc dn xut ca chng c
trong du m cng c xem l cc cht sinh ng th. Tn sut ung th da cao nhng ngi th nh si v th
my l do h s dng nhng thit b c bi trn bng du m c cht hydrocarbon thm l dn xut t
anthracene.
Ung th ngh nghip thng hay gp nht ngy nay l ung th ng h hp. Ngi ta xc nh mt s
ha cht hay hn hp ha cht trong mi trng ngh nghip c lin quan nhn qu vi bnh ung th phi. C
quan nghin cu ung th quc t IARC nh gi 10 ha cht hay hn hp khc nh l khi thi ca ng c
Diesel, beryllium v cc hn hp ca n, tinh th silica, cadmium v cc hp cht ca n c kh nng sinh ung th
ngi. Amian c l l cht quan trng nht gy ung th phi do ngh nghip. Ht bi (amian) s gy x ha phi
lan ta (asbertosis). Cc nghin cu t nhiu ni trn th gii cho thy s cng nhn cht do nhim asbestos
(asbertosis) th t l ung th phi hin din t 20-50% trng hp trong bu trung m mng phi chim t l
cao (thm ch thi gian tip xc khng di).
Ung th bng quang cng l mt trong cc ung th ngh nghip thng gp nht. Bt du t gia th k
XIX. Cng nghip nhum azo pht trin nhanh chng. Vo cui th k ny nhng trng hp ung th bng
quang u tin c pht hin cc th thng tip xc vi cht Anilin. Cht Anilin t n khng sinh ra ung
th ngi v ng vt nhng Anilin c cha nhiu tp cht 4-amindiphenyl c tnh sinh ung th. Cc cht chnh
gy ra ung th bng quang trong k ngh sn xut anilin l Benzidine, 2 naphthylamine v 4-aminodiphenyl.
8
Ht th Benzen c th lm c ch ty xng v gy ra chng thiu mu bt sn, nu tip xc Benzen vi
mc cao s gy ra bnh ung th bch cu ty cp. Ngoi ra n c th gy ra bnh a u ty xng v u lympho
c tnh. Sarcoma phn mm cng nhn tip xc vi cht dit c c gc phenoxy; ung th thanh qun gp cc
cng nhn tip xc vi hi acid v c mnh v ung th cc xoang cnh mi gp cng nhn tip xc vi
formaldehyd.
C quan nghin cu ung th quc t lit k 100 loi ha cht c th gy ra ung th biu m v cc
Sarcoma cc sc vt th nghim. Mt s ha cht ny c th gy ung th ngh nghip nhng phn ln cn li cho
n nay vn cha c bng chng.
2.4. Ha tr liu
iu tr ha cht chng ung th c th gy ra tn thng ADN v sinh ung th. Ngy nay nh pht hin
sm ung th v s dng nhiu phng php iu tr hiu qu nn thi gian sng thm ko di hn. Mt s ung th
iu tr khi nh pht hin giai on cha xm ln. V vy vai tr sinh ung th do ha cht cn phi c cn
nhc v c bin php sng lc nhng i tng ny.
Bng 1:Ung th lin quan n mt s thuc thng s dng trn lm sng
Tc nhn Cc ch nh Cc ung th phi hp
Cyclophosphamide Ung th cc loi UT bng quang, UT mu th ty cp
Melphalan a u ty UT mu th ty cp
Azathioprine, cyclosporine Bnh nhn ghp ty d gen U lymph c khng Hodgkin, ung th da
Nitrogen mustard, procarbazine Ung th cc loi UT mu th ty cp
Diethylstilbestrol Ph n UT m h, UT c t cung
Hot cht c cha phenacetin iu tr chng au Ung th b thn

9
Bng lit k cc loi thuc hay s dng c nguy c gy ung th. Nguy c gy ung th do thuc gia tng ph
thuc vo cc yu t:
- Tui s dng: tui cng tr cng tng nguy c.
- Thi gian tim tng gia s dng thuc v pht trin ung th trung bnh t 5 n 10 nm ngn hn so vi
40 n 50 nm trong phi nhim ha cht cng nghip.
- V s hin din ca cc yu t cng sinh ung th nh thuc l v phi nhim phng x
Thuc gy ung th nhiu nht l cc thuc chng ung th v cc loi thuc ny c chng minh gy ung th
thc nghim v cc loi ung th ch yu l ung th mu v cc loi u lymph c. Ung th mu th ty cp l bin
chng him ca cc thuc nhm alkyl. Suy gim min dch do ha tr, thuc c ch min dch, AIDS lm tng
nguy c mc u lymph c do nhim EBV.
Ngy nay, c nhiu thuc chng ung th hin i c hiu qu nn thi gian sng thm ca bnh nhn ung
th ko di hn v nhiu loi ung th c th cha khi do c pht hin sm v s dng ha tr a phng thc
nn vai tr sinh ung th do thuc ngy cng c ch c cc bin php sng lc v pht hin sm cc ung th
th hai nay.
3. Cc tc nhn sinh hc
Cc tc nhn sinh hc ung th ch yu l virus v mt s trng hp c vai tr ca k sinh trng v vi khun.
3.1. Virus sinh ung th.
Cc oncogen u tin c pht hin virus. Sau ngi ta pht hin virus tch hp vo ADN ca t bo vt ch
bnh thng v iu ha s tng sinh t bo mm. Cc virus sinh ung th ny gy nn ung th bng cch hot ha
gen bnh thng bn trong t bo ch.
C 4 loi virus sinh ung th ngi c m t.
- Virus Epstein Barr (EBV):

10
+ Loi virus ny c Epstein v Barr phn lp u tin bnh nhn ung th hm di ca tr em
vng Uganda, v sau ngi ta cn phn lp c loi virus ny trong ung th vm mi hng, bnh gp nhiu cc
nc ven Thi Bnh Dng c bit l Qung ng, Trung Quc v mt s nc ng trong c Vit Nam.
+ Virus Epstein-Barr thuc h Herpes c cho c vai tr bnh sinh ca 4 loi UT:
U lymph Burkitt.
Cc u lymph t bo B nhng ngi suy gim min dch, c bit nhng bnh nhn
HIV-AIDS v ghp c quan.
Mt s trng hp bnh Hodgkin.
Ung th biu m vm hng.
- Ung th gan v vim gan siu vi :
+ Cc nghin cu dch t hc cho thy vim gan siu vi B (HBV) c mi lin h vi ung th gan
nguyn pht (HCC). HCC thng gp nhng vng nh Chu Phi, ng Nam v Trung Quc. C 80% trng
hp HCC lin quan n nhim virus vim gan siu vi B. Virus vim gan B thuc loi virus ADN, xm nhp vo c
th gy vim gan cp, k c nhiu trng hp thong qua. Tip theo l thi k vim gan mn khng c triu chng.
Tn thng ny s dn n x gan ton b v ung th t bo gan. Ngoi ra x gan lm cho tin lng ca bnh
ung th gan xu i rt nhiu.
Pht hin nhng ngi mang virus bng xt nghim HBsAg (+). S lin h gia virus vim gan siu vi B v
ung th t bo gan dn n ung th gan c th phng trnh c bng cch s dng vaccine phng vim gan B.
+ Vim gan siu vi C (HCV): Mc d mi c ghi nhn l gy ra vim gan khng A, khng B.
ngi ta ghi nhn rng tn sut ung th gan nguyn pht gia tng gn y trong mt phn ca ngi dn Nht l
do c s nhim virus vim gan C mt cch thng xuyn. Vim gan do virus vim gan A khng lin h vi HCC.
- Virus gy u nh (HPV) typ 16-18, -33, 39: Ly truyn qua ng sinh dc. Loi ny c coi l c lin
quan n cc ung th vng m h, m o v c t cung. Hin nay c vaccine phng bnh.

11
- Virus sinh u ARN: Mc d cc nghin cu v retrovirus gip hiu r hn v c s phn t ca ung th
nhng ch c mt loi retrovirus ngi, virus gy bnh bch cu t bo T ngi type I ( HTLV-1: Human T cell
Leukemia Virus type I) c khng nh chc chn l nguyn nhn gy ung th. HTLV 1 gy bnh bch cu t
bo/u lymph t bo T thnh dch mt s vng ca Nht Bn v Carib nhng cng pht tn mt s vng khc.
3.2. K sinh trng v vi trng
- Mi tng quan gia k sinh trng v bnh ung th c bit nhiu nht l tnh trng nhim Schistosoma
vi ung th bng quang v gia nhim sn l vi ung th ng mt. Ngi ta tm thy nhiu nht Ai Cp, Irc,
Xung v Zimbabu.
- Helicobacter Pylori: Ngy nay cng c nhiu bng chng v s lin quan ca nhim khun d dy do H.
pylori vi u lymph d dy v ung th biu m d dy. S lin quan ny r rng hn vi u lymph d dy so vi
ung th biu m d dy. Mi lin quan ny c chng minh bng cc nghin cu dch t hc cng nh bng
vic pht hin H. pylori phn ln u lymph d dy. Bi v u lymph pht sinh trong m lymph thuc nim mc
d dy (MALT: Mucosa Asociated Lymphoid Tissue ) nn cn gi l u MALT (Maltoma). Nhng t bo B sinh ra
cc u ny nm vng ra ca cc nang lymph nn cn gi tn khc l u lymph vng ra (marginal zone
lymphoma). C ch sinh u ung th ca H. pylori cha tht r nhng c l do s tng sinh ca lymph T phn ng
vi H. pylori v cc t bo T ny hot ha mt qun th a dng cc t bo B bng vic ch tit cc yu t ha tan.
III. CC NGUYN NHN BN TRONG
1. Yu t di truyn
T khong 15 nm tr li y nh nhng tin b trong lnh vc nghin cu sinh hc phn t ngi ta
bit c s lin h cht ch gia cc bin i vt liu di truyn v s xut hin mt s bnh ung th.
Mt s tnh hung v mt di truyn: 80 - 90% ngi s b ung th do h mang gen gy hi U wilms, ung
th nguyn bo vng mc 2 mt v nhng bnh nhn a polip c tnh cht gia nh l th d v cc loi ung th
truyn theo tnh tri theo m hnh ca Mendel. Ung th tuyn gip th ty ( loi ung th tuyn gip c tit ra
Thyrocalcitonine) cng mang tnh cht di truyn r rt.

12
Nhng nm tr li y nh nhng nghin cu v gen, ngi ta phn lp c cc gen sinh ung th
(Oncogen) thc cht cc gen sinh ung th (proto-oncogen). Di tc ng ca mt vi tc nhn no tin gen
sinh ung th hot ha v bin thnh gen sinh ung th. T gen sinh ung th m ha sn xut cc protein v
men lin quan n qu trnh phn chia v bit ha t bo theo xu hng c tnh, v d trong bnh ung th bch cu
mn th ty, 90% t bo mm to huyt c s chuyn on 9/22.
Mt lai gen quan trng khc v cc gen c ch ung th (Anti-oncogen). Khi c th vng mt cc gen ny,
nguy c mc ung th s tng cao. Mt s gen c ch sinh ung th quan trng l gen P53 ca bnh ung th lin bo
vng mc mt, gen WT1 trong bnh u wilms, gen NF1 trong bnh a u x thn kinh ca Recklinghausen. Ngy nay
ngi ta c th tm ra c im a dng ca oncogen hay cc chui DNA c hiu tiu biu cho cc cht nh du
tnh "nhy" ca ung th. Cc h thng mang tnh tng i ca ca cc cht nh du di truyn da trn s pht
hin trc tip ca tnh a dng chui DNA vi cc men c ch. Ngi ta c th lp ra bn lin kt gen chi tit
ngi bng cch da v cc h thng va nu.
Bc nhy trong lnh vc di truyn v cc nghin cu v gen s cho nhiu hiu bit k th hn.
Mt s ung th di truyn:
1. Ung th i trc trng lin quan n di truyn: Trn 10% ung th i trc trng c lin quan n yu t
di truyn gm cc loi bnh sau:
+ a polip c tnh gia nh: L hi chng tri trn nhim sc th thng c t l xy ra khong
1/10.0000 ngi. Hng trm n hng ngn polip khu tr thnh i trng v thng bt u tui 30-40. Mt s
polip tr nn ung th ha. D phng bng cch ct i trng ton b trc giai on ung th ha.
+ Hi chng Gardner: Cng l hi chng biu hin a polip c tnh gia nh
+ Hi chng Turcot: Polip i trng kt hp u no
+ Hi chng Lynch: Ung th i trng khng polip phi hp vi nhiu loi ung th khc nh ung
th ni mc t cung, d dy, bng quang.

13
2. Ung th v c tnh gia nh: Di truyn trn nhim sc th thng, tnh tri nhng c tn sut khong 4
n 10%. C 2 loi:
+ Ung th v di truyn: do t bin gen, c tn sut mc bnh cao
+ Gia nh ung th v: Do trong gia nh cng phi nhim yu t nguy c cao ung th v nhng c
th khng mang gen di truyn. Cc yu t ny ch yu l ch n, tnh trng kinh t x hi, nh hng ca
hormone, tui lc c thai ln u. Ung th thng xy ra mun v ch vi thnh vin mc ung th v.
3. Cc ung th tuyn ni tit c tnh gia nh: Gm cc loi ung a tuyn ni tit typ 1 v 2. Loi ny t gp
hn.
4. Cc ung th tr em: C c im khc ung th ngi ln. Hnh thi hc rt ging vi cc khi u ca
phi, xm ln nhanh ra xung quanh, di cn xa sm nhng rt nhy cm vi ha tr. Cc loi thng gp:
+ Ung th nguyn bo thn kinh (neuroblastoma)
+ U Wilm
+ Sarcoma: thng gp sarcoma c vn
+ Ung th nguyn bo vng mc mt
2. Suy gim min dch v AIDS
Trn ng vt thc nghim s suy gim min dch lm gia tng nguy c b ung th. Ngi b suy gim
min dch mang tnh di truyn hay mc phi thng d b ung th v thi gian bnh ngn hn.
nhng bnh nhn ghp c quan, s suy gim min dch do dng thuc c ch min dch v corticoide liu
cao l r nht. Theo di mt thi gian di 16.000 bnh nhn ghp thn v c iu tr bng cc loi thuc c ch
min dch ngi ta thy nguy c mc bnh u lympho c khng Hodgkin tng 32 ln, ung th gan v ng mt
trong gan tng 30 ln, ung th phi tng 2 ln, ung th bng quang tng 5 ln, ung th c t cung gn 5 ln, cc
melanoma c tnh v ung th tuyn gip tng ln 4 ln. S suy gim min dch nng v ko di c bit trong ghp
ty xng cn tng cao nguy c nhim cc loi virus nh EBV, cytomegalovirus (CMV) v nhiu vi khun c hi
cng nh nhiu loi bnh do nm candida, aspergiluslm t l t vong do ghp tng ln ng k.

14
Ngi c HIV dng tnh, c bit khi chuyn qua giai on AIDS c nguy c rt cao mc sarcome Kaposi,
u lympho c khng Hodgkin v mt s ung th khc nh ung th vm, ung th c t cung. Sarcome Kaposi c th
xy ra bt c lc no sau khi b nhim HIV, tri li u lympho c khng Hodgkin c khuynh hng xut hin c a
suy gim min dch trm trng v nguy c c th gia tng n 75 ln so vi ngi bnh thng. Ung th bnh
nhn AIDS lm hn ch kh nng iu tr v tin lng sng thm rt ngn.
3. Ni tit t
Mt s hormone c tim nng gy ung th. C 3 loi ung th lin quan.
1. Ung th v: Dng liu cao, ko di estrogen c th gy ung th v chut. Cc nghin cu ng vt
cng cho thy estrogen l mt cht sinh ung th. Cc bng chng ny gi rng nhng ph n dung thuc trnh
thai c th tng nguy c gy ung th. Nhiu nghin cu cho rng s dng estrogen ngoi sinh khng c ngha gy
ung th v tuy nhin cng c mt s tc gi cho rng tnh an ton ca estrogen cha c chng minh.
2. Ung th ni mc t cung: Nhiu nghin cu bnh-chng cho rng s dng estrogen lm tng t l ung
th ni mc t cung. Tuy nhin nhiu nh khoa hc cho rng dung liu thp estrogen l an ton i vi nhng ph
n tin mn kinh v ph n ct b bung trng. Hu qu ca liu thp estrogen gy bnh long xng v tng
nguy c gy xng bnh l.
Cc nghin cu vn cn tip tc tm ra nguy c gy ung th ni mc ca estrogen.
3. Ung th tuyn m h: Vo nm 1947, ngi ta cho rng estrogen tng hp nh l DES
(diethylstilbestrol) dung np tt ph n c thai, an ton cho thai nhi v c hiu qu phng sy thai nn c k
n rng ri. Cho n khi c mt nghin cu vo nm 1977 cho thy nhng ngi con gi ca nhng b m c
iu tr bng DES tng t l lon sn m h v ung th nn b cm v ngy nay bin chng ny khng cn xy
ra.
4. Ung th tin lit tuyn: Yu t nguy c quan trng nht ca ung th tin lit tuyn l tui nhng
testosterone sau khi c chuyn ha thnh dihydrotestosterone l mt cht gy tng sinh nhanh t bo ca tuyn
15
tin lit. V vy Dihydrotestosterone c th lin quan n chuyn dng c tnh v cc nghin cu ang thc hin
quyt nh s dng cht c ch sn xut Dihydrotestosterone c gim t l ung th tin lit tuyn hay khng.
KT LUN
Thng qua bi ny chng ta nhn thy nguyn nhn gy ung th rt a dng, trong vai tr ca yu t mi
trng chim t l cao gy ung th ngi. Ht thuc l, phi nhim vi cc ha cht gy ung th trong mi
trng ngh nghip, phi nhim vi phng x gia tng nguy c gy ung th. Ch n khng an ton, suy gim
min dch, s dng thuc c t bo v s dng hormone cng c vai tr tng nguy c ung th. Nhiu nghin cu
thng k khng nh vai tr ca yu t di truyn gy ung th ngi. Tuy nhin ung th khng ch c gy
nn bi mt tc nhn duy nht m c s tc ng bi nhiu yu t lm cho t bo bnh thng thay i thnh t
bo ung th. S chuyn dng t t bo bnh thng thnh t bo ung th xy ra khi mt hoc nhiu oncogen c
hot ha.
Mc tiu quan trng ca vic nghin cu nguyn nhn ca ung th l cung cp thng tin nhm hng n
vic d phng ung th. Xc nh c vai tr ca mt s yu t sinh ung th thng gp nh thuc l, cc ph gia
trong thc phm, cc virus sinh ung th l rt quan trng, t ra cc phng php phng bnh tch cc nh
phong tro phng chng ht thuc l, cc chng trnh tim chng m rng phng vim gan B, nhm h thp t l
mc bnh.
CU HI KIM TRA NH GI
1. K c cc nguyn nhn ph bin trong mi trng gy ung th ?
2. Xc nh c nhng nguyn nhn c th d phng c cho nhng li khuyn b ch d phng ung th ?

16
TI LIU THAM KHO
I. TI LIU TING VIT
1. i Duy Ban. 2000. Phng bnh ung th.. Nh xut bn Y hc. Trang 47-122
2. Nguyn B c. 1999. Bi ging ung th hc.. Nh xut bn Y hc. Trang 28-34
3. L nh Roanh. 2001. Bnh hc cc khi u. Trang 87-97
4. Richard R. Love.1995. Cm nang ung bu hc lm sng (Ti liu dch t Manual of Clinical Oncology). Trang:
71-123. Nh xut bn Y hc Tp HCM.
II. TI LIU TING ANH
1. Bruce D. Cheson. 2004. Oncology (Medical Knowledge Self-Assessment Program). pp 1-16. ASCO.
1
Chng V
D PHNG UNG TH
Mc tiu hc tp
1. M t c cc bc d phng ung th
2. K c cc phng php sng lc v pht hin sm ung th v, ung th c t cung, ung th
i trc trng.
I. I CNG
Vn chn on v triu chng nhiu loi ung th c nhiu tin b vt bc trong
thi gian y, tuy nhin s ngi mc bnh v t vong do ung th cn cao v d bo tip tc gia
tng trong thi gian ti. Nu ung th c cha khi hu qu v ti chnh v th lc v tnh cm
vn bao trm qung i cn li ca ngi bnh.
Cc nh dch t hc c lng c khong 70-80% cc bnh ung th l do nguyn nhn
mi trng, do chng ta c th d phng c bnh ung th bng cch ngn cn vic tip xc
vi cc nguyn nhn gy ra ung th. V th v l thuyt chng ta c kh nng lm gim t l mc
bnh v t l t vong do ung th khong hn 80%.
II. S PHNG NGA BAN U (Phng bnh bc mt)
Phng nga ban u l nhm c gng, loi tr hoc gim ti a s tip xc vi cc
nguyn nhn gy ra ung th. y l phng php d phng tch cc nht.
1. Yu t nguyn nhn v phng nga
1.1. Ht thuc l
S nghi ng c mi lin h gia ht thuc l v ung th c cp n t 200 nm
v trc. Bo co u tin nm 1795 nu ra mi lin h gia thuc l v ung th mi. Cng

2
trnh nghin cu u tin nm 1928 kt lun l ung th gp nhiu hn nhng ngi nghin
thuc l. Trong thp nin 50 nhng cng trnh nghin cu Anh v Hoa K chng minh mi
lin h nhn qu gia ht thuc l v ung th phi. T nm 1960 t l ht thuc l M, Canada,
Anh, c gim t 42% cn 25% Tuy nhin theo thng k ca T chc Y t Th gii t l ht
thuc l cc nc ang pht trin gia tng trung bnh hng nm khong 8%.
n nay ngi ta nhn thy thuc l gy ra 30% cc loi ung th, 90% ung th phi,
75% ung th khoang ming, thanh qun, thc qun, 5% ung th bng quang. Do ngi thy
thuc phi t chc cc phong tro phng chng thuc l nhm tuyn truyn cho nhng ngi
nghin thuc gim dn n ngng ht .
+ Khuyn khch nhng ngi ang ht thuc ngng ht
+ H tr cho ngi bnh ngng ht
+ T chc thm khm theo di nh k
+ Ch tuyn truyn i vi nhng thanh thiu nin cha bao gi ht thuc v
ph n mang thai.
1.2. Ch n
ng sau thuc l nhiu yu t dinh dng c xp nguyn nhn quan trng th hai gy
bnh ung th v t vong.
Ch n tiu biu Ty phng v mt s nc pht trin gm nhiu tht v cht bo c
lin quan vi ung th i trng. Nhiu nghin cu gn y nhn mnh rng nguy c tng ln
vi ch n t rau, t tri cy do thiu vi loi sinh t (A,C v E), cc cht vi lng (selen, st),
v cht si trong ch dinh dng .

3
cc nc ang pht trin, aflatoxin, mt sn phm ca nm mc trn thc n l nguyn
nhn chnh gy ra ung th gan; cc Nitrit v Nitrat trong thc phm hong khi c vai tr lm gia
tng t l bnh ung th thc qun, d dy.
Mi c gng ngn nga ung th hng n vic thay i ch n t tht, tng cng
n nhiu hoa qu, rau v cc loi vitamin nht l betacaroten. Trnh n nhiu m , gia v v n
cc thc n b mc.
1.3. Ha d phng
Ha d phng l ung mt ha cht, cc sinh t chng hn nhm ngn chn qu trnh sinh
ung th. Ha d phng ch mi thc s pht trin nhanh trong nhng nm gn y. Nhiu ha
cht khc nhau ang c dng nhm nh gi hiu qu ca ha d phng: Retinoid v caroten,
nhiu cht chng xy ha nh sinh t C v E, Selen, calci, thuc khng vim khng steroid
(NSAIDS) nh aspirin, sulindac v tamoxifen, cht khng estrogen c s dng rng ri
iu tr ung th v. Hoa K mt th nghim ngu nhin nhm ngn chn ung th tin lit
tuyn bng finasteride, cht ngn cn 5-alpha reductase.
1.4. Virus
C 4 virus c bit l nguyn nhn gy ung th ngi l: Virus vim gan B, virus
Epstein-Barr, Virus bu gai ngi (human papilloma virus-HPV) v virus gy bnh Bch cu
T ngi. (HTLV)
Vim gan B cng vi nhim aflatoxin c xem l nguyn nhn gy hu ht ung th gan
nguyn pht cc nc Chu Phi v ng Nam . Chng nga rng ri vim gan B cho tr mi
sinh lm gim t l mc bnh v t vong do ung th gan nguyn pht.

4
Nhiu vacxin cng ang lu hnh i vi virus Epstein-Barr, loi ny c coi l nguyn
nhn chnh gy ung th vm v limphoma Burkitt. Thuc chng dng cho HPV v HTLV ang
giai on khi u.
1.5. Bc x mt tri
Bc x cc tm (UV) do phi nng qu c xem l tc nhn chnh gy ung th da (c
v khng c sc t), c bit lin quan vi cc sc dn c mu da sng. T l ung th cao nht
c v Ai-len. Cn tuyn truyn cho ngi dn trnh phi nng qu mc, dng cc phng tin
che nng (o, nn m), dng thuc bi bo v da.
1.6. Tip xc ngh nghip
Tip xc ngh nghip c xc nh sm nht trong s nguyn nhn gy ung th. S
lng cht sinh ung th c bit nhiu hn c l trong lnh vc cng nghip. V d: Asbestos l
cht sinh ung ngh nghip gy ung th phi v trong m mng phi.
hu ht cc nc v sinh cng nghip v bo h lao ng c thc hin mt cch
nghim tc nhm h thp t l bnh nhn mc bnh ung th do ngh nghip.
1.7. Tc dng ph do dng thuc
Mt s phng php chun on hoc iu tr cng c tnh cht sinh ung th, c bit l
bng x tr v ha tr. Vi cht ni tit dng nga thai hay iu tr ph khoa cng c nguy c sinh
ung th v sau. V d: ung th m o nhng b gi c tip xc vi diethylstilbestrol do ngi
m s dng vo u thai k lm gim cn bun nn v nga da sy thai.
Thy thuc lm sng cn phi lu n cc cht sinh ung th c bit l cc ni tit t
n, cc cht chng ung th nhm c nhn Alkyl, phi c k hoch theo di pht hin nhng
ung th th pht do dng thuc hoc cc phng php iu tr gy ra.

5
1.8. Yu t di truyn
Lch s gia nh t lu cng c xem l yu t nguy c hay gp ca mt s loi ung th
nh ung th v, ung th i trc trng, ung th vng mc mt, bnh kh da nhim sc t. Chin
lc d phng bc u nh dng Tanoxifen nh th nghim ha d phng cho nhng ph n
c tin cn gia nh mc ung th v. Ngoi ra ngi ta cng phi lu d phng bc hai
(chng trnh sng lc) i vi ngi c tin s gia nh b ung th.
2. Nhng yu t nguy c khc
Bc x ion ha cng l yu t nguy c ca nhiu dng ung th, v d sau ln nm bom
nguyn t Nht, hoc sau tai nn l phn ng nguyn t Chernobyl.
Mt yu t nguy c ung th mi c bit gn y l t hot ng thn th, lm vic v
gii tr c th gip phng nga ung th i trng.
Nhiu ung th c bit c lin quan vi AIDS. Mi bin php ngn nga bnh AIDS
cng l n lc d phng mt s bnh ung th.
III. SNG LC V PHT HIN SM ( D phng bc 2)
Sng lc l cch nh gi ton th dn s hay tng c nhn hon ton khe mnh v mt
lm sng, pht hin mt ung th tim n hay tin ung th, hu c th iu tr khi. S sng lc
da trn quan nim rng s pht hin sm ung th trc khi di cn xy ra th hiu qu iu tr s
tt hn l lc cc triu chng xut hin.
Mt ung th c xem l l tng cho vic sng lc khi giai on tin lm sng c th
pht hin c ca n tn ti kh lu trc khi cc triu chng xut hin v di cn xy ra.

6
1. Sng lc ung th v
Ung th v l ung th ng hng u n gii cc nc pht trin cng nh ang pht
trin. Chng trnh sng lc ung th v lm gim t l t vong do ung th ny.
Cc phng sng lc bao gm:
1.1. Khm lm sng tuyn v (CEB: clinical examination of the breast)
L mt phng php thng dng pht hin ung th v. Cc bc s chuyn khoa khuyn
nn khm lm sng tuyn v hng nm cho tt c ph n trn 40 tui nh l mt phn ca s
kim tra sc khe ton din .
1.2 T khm v (BSE: Breast self - examination)
L mt k thut t tn km v v hi i vi tuyn v. Thc hin t khm v mt thng
mt ln sau khi sch kinh. Nu ngi ph n c hng dn t khm v cn thn s pht hin
ra bnh khi u cn nh, hch di cn t hn nhng ngi khng thc hnh t khm v. Do vy
phng php t khm v nn c ph bin rng ri trn cc phng tin thng tin i chng.
Hnh 1:Cc bc t khm v

7
Cc bc t khm v
1.3. Chp tuyn v (Mammography)
Phng php ny hon thin v mt k thut trong nhng nm gn y v c p
dng rng ri sng lc pht hin sm, cng nh chn on ung th v.
Vi ph n trn 40 tui trong nhm nguy c cao mi nm nn chp v khng chun b
mt ln, ph n trn 50 tui nhy ca phim chp v vt hn 85% v c hiu l 95-99%.
Hnh 2: Chp nh nh
8
2. Sng lc ung th c t cung
Ung th t bo gai ca c t cung thng pht trin theo sau d sn trong biu m v ung
th ti ch (CIN: Cervical intraepithelia neoplasia). Khong 20% cc thng tn trn pht trin
thnh ung th xm ln trong vng 20 nm. Cn c th pht hin c bng xt nghim t bo
bong. Nh th ung th c t cung c th phng nga nu sng lc c tin hnh bng Paptest
mt cch chnh xc hay t bo hc m o mi nm mt n hai ln ph n trn 30 tui c
gia nh.
T bo hc c t cung l mt bin php hu hiu phng nga ung th c t cung xm
ln v t vong do ung th c t cung. nhng nc p dng chng trnh sng lc ung th c
t cung bng Paptest t l cc trng hp ung th c t cung xm ln gim 30%.
cc a phng khng c phng tin lm Paptest c th khm c t cung bng m
vt cho cc ph n trn 30 tui. Nu pht hin c nhng tn thng nghi ng s chuyn n
phng khm chuyn khoa chn on v iu tr.
C th kt hp khm bng mt vi lm th nghim Lugol soi c t cung phng i cc
thng tn c t cung, khot chp c t cung va chn on va iu tr cc ung th tin
xm ln.
3. Sng lc ung th i trng v trc trng
nhiu nc pht trin, ung th i trc trng ng hng th hai sau ung th phi. V
triu chng lm sng thng khng r rng nn bnh nhn n khm giai on tng i tr.
Tuy nhin vi s xut hin nhiu loi xt nghim sng lc ung th i trc trng, theo l thuyt l
ung th l tng chn on bnh trc khi c triu chng xut hin.
Chin lc sng lc nn nhm vo cc i tng c nguy c cao v tp trung vo tui
50-70 tui.
9
Cc test sng lc.
+ Xt nghim mu tim n trong phn (FOBT: Fecal occult blood tests).
Pht hin hot ng Peroxidase ca huyt cu t. Cc xt nghim sng lc cho thy
khong 2% FOBT dng tnh v gi tr d don ca test cho c u tuyn lnh v ung th gia 20-
30%. Xt nghim dng tnh gi do thc n v thuc cng c xy ra.
+ Ni soi:
Soi i trng ? (Sigma) ln n 20cm s dng nh mt xt nghim n c hay kt
hp vi FOBT. Soi ton b i trng c u im l nhy v c hiu cao v nhn c ton
b khung i trng nhng gi thnh cao v nguy c thng rut (20/00 cc trng hp soi i
trng) gii hn vic sng lc theo phng php ny. Ch nn soi ton b khung i trng vi
cc i tng c nguy c cao vi xt nghim FOBT dng tnh.
Hnh 3: Ni soi v chp khung i trng c thuc

10
4. Sng lc cc ung th khc
4.1. Ung th hc t
y l loi ung th c th sng lc tt yu t nguy c l tin s gia nh, tin cn b bng
nng hay c tn nhang, cc nt rui trn c th. Phng php sng lc ch yu l khm bng
mt, khm t m vi nhng cn b y t c hun luyn tt.
4.2. Ung th phi
Hin cha c bng chng cho thy sng lc ung th phi bng chp Xquang phi v t
bo hc cht m c nh hng n t l t vong, tuy nhin chp Xquang phi nh k hng nm
cho nhng ngi nghin thuc l trn 45 tui c th pht hin c u phi khi cn nh.
4.3. Ung th vm
c sng lc bng cch o lng khng th IgA ca virus Epstein - Barr nhng vng
c t l mc bnh cao.
4.4. Ung th hc ming v hu
Cc i tng c thi quen nhai thuc l v nhai tru, ht thuc v ung ru u c
nguy c cao. Vic thm khm bng mc kt hp vi cc chng trnh gio dc cho dn chng
gp phn vo vic pht hin ung th v cc tnh trng tin ung th sm hn.
4.5. Ung th d dy
Chng trnh sng lc bng chp X.quang d dy v soi d dy c nh gi cao
Nht.
Hn ch ca sng lc l gi thnh cao, do nn p dng cho nhm c nguy c cao ( tui,
tim s vim lot d dy mn tnh).

11
4.6. Ung th gan nguyn pht
Sng lc bng cch o v Alpha Foetoprotein trong huyt thanh nhng i tng b
vim gan siu vi trng B.
Siu m c dng theo di cc trng hp c kt qu bt thng.
4.7. Ung th tin lit tuyn
3 xt nghim c kh nng pht hin bnh khi cha c triu chng l: thm khm trc
trng bng tay, siu m qua trc trng, khng nguyn c hiu ca tin lit tuyn.
4.8. Ung th tuyn gip
Cc i tng c chiu x vo vng u c s c nguy c cao, cn phi c thm
khm nh k, xt nghm calcitonin v Thyroglobulin.
III. KT LUN
Vic sng lc pht hin bnh ung th khi cha c triu thng c kt qu kh quan i
vi mt s loi ung th: ung th v, c t cung, d dy, i trng v ung th hc t. c hiu
qu, vic sng lc phi lm gim t l t vong v gim t l t vong do cc chng trnh sng lc
mang li ty thuc vo s pht trin cc chng trnh sc khe ton dn.
CU HI KIM TRA NH GI
1. M t c cc bc d phng ung th ?
2. K cc phng php sng lc v pht hin sm ung th v, ung th c t cung, ung th i
trc trng ?
12
TI LIU THAM KHO
I. TI LIU TING VIT
1. i hc Y H Ni, 1999. Bi ging ung th hc, nh xut bn Y hc 1999, trang 34-39.
2. Phm Thy Lin, 1999. Lm th no pht hin bnh ung th sm nht, nh xut bn
Nng, trang 16-21.
3. UICC, 1995. Ung th hc lm sng 1995, trang 134-137
II. TI LIU TING ANH
1. International Agency for Research on Cancer. Working Group on Evaluation of Cervical
Cancer Screening Programmes: Screening for squamuos cervical cancer: duration of low risk
after results of cervical cytology and its plication for screening policies 1985. BMJ; 293: 6599.
2. Kross LG, 1989. The Papanicolaou test for cervical cancer detection: a triumph and a tragedy.
JAMA; 261;737.
3. Mandel JS, Church TR, Ederer F, et all, 1999. Colorectal cancer mortality: effectiveness of
bienial screening for fecal occult blood. J natl Cancer Inst; 91: 434
1
Chng VI
THM KHM KHI U
Mc tiu hc tp
1. M t c cc nguyn tc thm khm khi u
2. Phn bit c u lnh tnh v c tnh v xut c cc xt nghim cn bn chn on
khi u.
I. I CNG
khi u d l lnh tnh hay c tnh cng cn phi c pht hin sm, phi c thm
khm t m c c mt chn on ng, chnh xc v c mt phng php iu tr tt nht
i vi cc khi u. c nhng chn on s b trc khi gi n cc c s chuyn khoa th bt
c thy thuc no cng c th lm c. Mt khi u c th pht hin mt cch tnh c bi bnh
nhn hoc c pht hin qua nhng t khm sc khe hoc t chc khm sc khe hng lot
ti cng ng.
1. nh ngha
Hin nay c rt nhiu nh ngha v khi u. Chng ta tham kho cc nh ngha m c
nhiu ngi chp nhn nht.
1.1. nh ngha ca Abedanet Khi u l mt t chc tn sinh, kt qu ca s tng sinh khuych
i t nhng t bo ca mt t chc trong c th, c chiu hng tn ti v ln ln mt cch
khng gii hn.
1.2. nh ngha ca Willis Theo Willis khi u l mt t chc khng bnh thng pht trin v
hn v vn tn ti mc du ly i nhng yu t kch thch.

2
2. Mt s c im chung
T nhng nh ngha trn ta rt ra mt s c im chung, c tnh cht c trng sau :
U l mt t chc tn sinh (Neoplasme) nhng c cu trc mang c im ca t chc
sinh ra n.
V d :
+ U v l lnh tnh (u x tuyn v) hoc l mt ung th, nhng bn cht ca n l
nhng t bo mang c im ca t chc tuyn v, hoc t chc ca ng dn sa.
Cn phn bit u vi mt t chc nhim trng, m v lm sng cng s c mt khi u,
nhng thc cht n ch l mt t chc gi u bi v :
+ N ch lm thay i mt cu trc c t trc, n khng phi l mt t chc
tn sinh.
+ N c c im ca mt t chc nhim trng v tn ti gn lin vi qu trnh
nhim trng.
Tt c mi c quan trong c th u c th pht sinh u.
C nhng u khng c th pht hin c qua thm khm lm sng nht l nhng u cn
nh hoc nm su trong c th.
Mt c quan trong c th c th c u lnh v u c, c khi bao gm c u lnh v u c cng
tn ti trong cng mt thi im.
V d :
+ Trn mt tuyn v ca mt bnh nhn c th tn ti mt u x bn cnh mt ung
th v.
3
II. KHM U
Vic thm khm pht hin v nh gi mt khi u i hi phi t m, phi ton din,
c khi c tin hnh nhiu ln v phi kt hp gia lm sng v cn lm sng
1. Khm lm sng
1.1 Yu cu
Vic thm khm phi c tin hnh phng khm, hoc bung bnh vi nhng iu
kin cn thit theo nhng chuyn khoa.
Bnh nhn c th c khm t th nm, ngi hoc nhng t th c bit ty thuc vo
v tr ca u.
V d :
+ Bnh nhn c th ngi lc khm bu c, khm u.
+ Bnh nhn nm khm nhng u bng.
+ Bnh nhn nm t th sn khoa trong nhng thm khm khi u vng hu mn
trc trng hoc nhng u thuc sn ph khoa...
Phi bc l r vng nh khm, V d :
+ Khm v bu c : phi bc l r vng c, phn trn ca ngc.
+ Khm v : phi bc l r vng ngc, c v nch.
Phi khm nh nhng, theo mt trnh t nht nh v phi lun lun i chiu, so snh vi
bn lnh.
4
1.2. Khm c th
1.2.1. Nhn
xc nh v tr ca u, c bit vi nhng khi u nm nng, bng mt thng c th
s b nh gi c.
Xc nh nhng thay i da v t chc ngay trn u hoc xung quanh u : c lot da, chy
mu, ph n, ph i cc mch mu xung quanh u hay khng.
S b xc nh c ranh gii, kch thc ca u.
1.2.2. S Vi cc khi u
Xc nh c kch thc, c th kt hp vi dng c, thc o nh gi chnh xc
kch thc ca khi u. Vi nhng u c tnh, vic nh gi chnh xc kch thc ca khi u l mt
yu cu cn thit c c mt phc iu tr thch hp.
Xc nh mt : mm, chc, cng ...
nh gi ranh gii : Gii hn r thng gp trong cc u lnh.
S cn nh gi mc di ng ca u, nhng u khng xm ln vo cc t chc k cn
xung quanh th thng di ng.
Vi cc h thng hch lin quan : phi s k pht hin c hoc khng c hch, s
lng, mt ca hch, di ng v kch thc.
V d :
+ Vi cc bu gip : phi xc nh cc hch vng mng cnh, cc hch gai vng
sau c c n chm, cc hch cnh kh qun v vng thng n.
+ Vi cc u vng v : phi nh gi cc hch vng hm nch, hch v ngoi, hch
gia cc c ngc (hch Rotter interpectoral), hch thng n.

5
+ Vi cc u vng sinh dc ngoi, vng trc trng, tng sinh mn : Phi kim tra
k h thng hch vng bn v hch chu hai bn.
+ Vi cc ung th tiu ha, phi pht hin cc hch Troiser vng thng n
bn tri.
1.2.3. G
Ch yu nh gi cc u su vng bng, ngc, nhng thay i v kch thc ca u,
nhng c quan trong c u pht trin : u d dy, u gan, nhng u trong phc mc v khoang
sau phc mc, nhng u phi, nhng xut tit trong bng hoc khoang mng phi do u ...
1.2.4. Nghe
Cng cn thit khi khm khi u phi, nhng u c biu hin chn p hoc ph i mch
mu: bu gip, cc u nm trn ng i ca mch mu ln...
2. Khm cn lm sng
Khm cn lm sng s b nh gi, mt chn on bc u. Tuy nhin mun nh
gi tht ng n, tht chnh xc th phi kt hp vi cc phng tin cn lm sng h tr vi
lm sng, tuy nhin cng ng cu k i hi phi lm qu nhiu xt nghim trng lp nhau,
phin phc, tn km v mt qu nhiu thi gi cho bnh nhn.
2.1. T bo hc (cytologie)
T bo hc ra i th k trc, vo nm 1825 do bc s Lebert xut v chnh Lebert
cng l ngi xut ra phng php chn on t bo hc bng chc ht kim nh v ngy nay
vai tr ca n khng th thiu trong vic chn on, iu tr v theo di, d phng i vi cc u
v c bit l cc u c tnh.
6
y l mt phng php n gin, t tn km, d lm m bt c mt c s no cng c
th lm c v c th p dng c nhiu v tr ca u trong c th.
Phng php ny nhy, ng tin cy. S sai lch gia t bo v gii phu bnh l l
khng ng k. Theo gio s Nguyn Vng b mn Gii phu bnh Trng i hc Y khoa
H Ni v cc Gio s bnh vin K H Ni th chnh xc ca chn on t bo so vi gii
phu bnh l l khong t 80 - 90%.
Cc phng php t bo hc :
+ T bo bong : tc l tm t bo t cc cht bi tit (trong m, dch d dy, dch
bng, dch mng phi...) hoc tm cc t bo do pht knh trc tip t trn b mt ca u bong ra
tm t bo m o qua xt nghim papanicolaou).
+ T bo chc ht : dng bm tim vi kim nh, chc ht trc tip vo khi u,
hoc c th kt hp chc ht di s ch dn ca siu m. y l mt phng php tt, tiu bn
ly chnh xc.
Gi tr xt nghim t bo :
+ Nu kt qu (+) tc l tm c t bo chnh xc chn on, th n c gi tr
quyt nh chn on.
+ Nu kt qu (-) iu khng c ngha l ph nh chn on, v c nhng
trng hp (-) gi do chc khng ng ch.
Ngy nay ngi ta cn cp nhiu n nhng trng hp (+) gi, tc l nhng trng
hp nhm ln trong chn on, c bit i vi cc u c tnh, c th nhm ln mt s trng hp
c bit m hnh thi ca mt s t bo c thay i d nhm vi hnh nh ca t bo ung th. Tuy
nhin nhng trng hp ny vi t l khng cao lm v cn ph thuc vo kh nng ca ngi
c tiu bn.
7
2.2. T chc hc (Histologie)
N c gi tr chn on. N va nh gi c v mt hnh thi hc ca t bo u, va
nh gi c cu trc ca t chc m ca khi u. Tuy nhin mt xt nghim ca t chc hc
phi t yu cu :
Mu bnh phm phi ln lm c tiu bn v khi cn thit phi lm nhiu tiu
bn.
Phi ly ng ch yu cu.
Mt u lnh tnh c th bm sinh thit hoc bc u lm gii phu bnh l.
Mt u c tnh, nu c th nn bc trn u lm gii phu bnh l, hoc lm gii phu bnh
l tc th c mt kt qu ngay trn bn m v c phng thc gii phu kp thi, trnh nhng
di cn do phu thut gy nn, c bit nhng u : hc t c tnh, K tinh hon ...
2.3. X quang
Rt c gi tr chn on cc khi u su : u phi, u d dy, thn, xng...
c bit hin nay vi nhng tin b ca trang b my mc v k thut ngy cng tin tin,
ngi ta c th pht hin kh chnh xc ngay c cc u su m lm sng khng th vi ti c,
v nhng u rt nh ng knh ch 1 cm.
Chp X quang c th n thun (chp khng chun b) hoc kt hp vi cht cn quang
(chp d dy, chp UIV thn, chp ty sng, chp mch mu, ng dn sa...). C th p dng
nhng phng php c bit chp ct lp TDM (Tomodensitometry), chp ct lp vi tnh CT

8
(Computed Tomography), chp cng hng t ht nhn MRI (Magntic Resonnance Imaging),
chp c kt hp vi ng v phng x (Scintigraphie) p dng trong chp bu gip, thn ...
2.4. Siu m (Echographie)
Ngy nay c p dng rt nhiu pht hin chn on v theo di iu tr cc khi u.
Tuy rng n khng quyt nh chn on, nhng n gi , hng n mt phng php chn
on xc nh. Siu m l mt phng tin tt pht hin sm v theo di cc khi u ca ng
tiu ha, tit niu, h hp v u nm su trong bng, lng ngc ...
2.5. Cc xt nghim v dch th
Bao gm cc xt nghim pht hin v theo di s tn ti v pht trin ca cc u trong
c th.
Cc xt nghim v mu trong cc loi ung th bch cu.
Pht hin mt s men bt thng xut hin khi c khi u trong c th:
+ Cht FP (Alphafoetoproteine) : l mt cht ch c trong thi k bo thai v lc
mi khong 10.000-150.000 mcg/ml, ngi trng thnh cn khong 1-15 mcg/ml, c bit
tng cao trong K gan nguyn pht.
+Khng nguyn bo thai ung th CEA cng l mt cht glycoprotine, c nhiu
trong ung th i trng, phi, d dy.
+ Phosphatase axit c nhiu trong ung th tin lit tuyn.
+ Hormon HCG ch im mt ung th rau thai v tinh hon, bnh thng trong
mu c 0,4 mcg/ml.
9
III. CN PHN BIT U LNH VI U C TNH
S phn bit gia mt u lnh tnh v u c tnh c mt ngha rt quan trng. S phn bit
nhiu khi rt d vi mt s u nh, tuy nhin c nhng trng hp rt kh, phi kt hp cht
ch gia thm khm t m v lm sng v cc phng php cn lm sng mi phn bit c.
1. U lnh tnh
1.1. Lm sng
Phn ln u pht trin chm, c nhng u tn ti lc mi sinh (u mu). C nhng u pht
hin c trong qu trnh hnh thnh ca c th v cng tn ti lu nm vi bnh nhn : bu c
n thun, u b, u m, u xng lnh tnh ...
U thng c mt mm hoc chc.
+ Mt mm: bu gip, u mu, u b, u m v cc u phn mm lnh tnh khc ...
+ Mt chc v n hi: u x cc loi nh u x tuyn v, u x tin lit tuyn, u
x t cung.
Ranh gii thng r rng, v phn ln u c v x bao bc.
Thng di ng d v khng xm ln vo cc t chc k cn v khng di cn.
Nu c ct b u khng ti pht.
1.2. V mt t bo hc v t chc hc
V mt t bo hc: U lnh tnh c s tng sinh ca t bo v t chc m xung quanh,
nhng khng c s o ln cu trc ca t bo v s thay i hnh thi gia cc t bo vi nhau.
V mt t chc hc : Trong u lnh tnh khng c s o ln cu trc ca t chc.

10
2. U c tnh
2.1. Lm sng
Khi c mt u c tnh pht hin trn lm sng, theo di tin trin thy u pht trin rt
nhanh. Bnh thng mt khi u khi pht hin c vi ng knh 1cm3 (tng ng 1 t t
bo) v phi mt khong 7-10 nm. Nhng khi pht hin c nh vy i khi pht trin n
giai on ton pht ch l mt khong thi gian rt ngn v d ung th gan, ung th d dy, ung
th phi ...
Mt khi u thng rn.
B mt thng ln nhn, g gh do s pht trin khng u ca u.
Ranh gii khng r rng, t hoc khng di ng do thng hay xm ln ra cc t chc k
cn. Chnh v vy m khng th bc u m phi ct b u v rt d ti pht.
U c tnh thng di cn xa bng ba con ng : xm ln k cn, di cn theo bch mch v
ng mu.
2.2. V mt t bo hc v t chc hc
Xt nghim u c tnh v mt t bo hc phi da vo 4 tiu chun :
- S thay i ca nhn.
- Mi quan h ca nhn v nguyn sinh cht.
- Mi quan h gia cc t bo vi nhau.
Vi mt u c tnh, v phng din t bo hc, c nhng s bin i c trng : qu sn,
lon sn, d sn (tm thy cc nhn qui, nhn chia) v bt thc sn (tc l khng c s pht trin
y cc dng t bo t non n gi m ch yu ch thy cc t bo non).

11
V t chc hc : thng c s o ln cu trc ca t chc u ( tc l c s xm ln ca t
chc c tnh v cu trc m xung quanh).
CU HI KIM TRA NH GI
1. Nu cc nguyn tc thm khm khi u ?
2. Phn bit c u lnh tnh v c tnh v xut c cc xt nghim cn bn chn on
khi u ?
TI LIU THAM KHO
I. TI LIU TING VIT
1. i hc Y H Ni, 1999. B mn Ngoi, Triu chng hc Ngoi khoa, trang 104 126.
2. L nh Roanh, 2001. Bnh hc cc khi u, nh xut bn Y hc, trang 129-136.

1
Chng VII
CHN ON BNH UNG TH
Mc tiu hc tp
1. Trnh by c cc phng php chn on ung th hin nay.
2. Nu c phng php chn on giai on theo TNM v mt s phng php phn loi khc
c p dng nh: FIGO, Ann-Arbor v Dukes.
Mi v tr ca ung th c cc triu chng pht hin c hiu cho v tr ,tuy nhin hu
ht cc triu chng pht hin xut pht t sinh l bnh hc v c bit l s pht trin c trng
ca khi u.
Mt khi nhng triu chng xut hin,ngi thy thuc nn thc hin mt s th tc
chn on :
Chn on cng sm cng tt, s dng cc phng php thm khm trnh gy au n,
kh chu cho ngi bnh nu c th c.
Nhanh chng thc hin sinh thit khi u a ra chn on chnh xc v gii phu bnh
hc.
Kim tra v lm sng v cn lm sng xc nh khi u ang cn tin trin ti ch hay
di cn xa.
Xc nh chnh xc giai on ung th.
a ra phc iu tr u tin da vo bnh n c iu tr trc .
Chn on mun dn n iu tr mun v ng nhin s nh hng khng tt n kt
qu iu tr.
2
Khi u iu tr nhanh v thch hp s to ra kh nng thnh cng tt nht cho bnh
nhn.
I. CC HI CHNG CHN ON
1. Hi chng u
S xut hin khi u c th l triu chng pht hin duy nht, hoc l trc tip hocnhng
ri lon do khi u to ra.Khi ung th xm ln cu trc lnh ln cn, khi u thng t di ng,
b khng u, s thy cng.
Mt vi hi chng khi u nh sau:
Mt khi u v
U no vi ph n no (to ra tng p lc ni s vi au u, nn ma v tai bin mch
no).
Kh nut do khi u thc qun
Chn p niu qun v niu o do ung th tin lit tuyn
Hi chng bng quang b do ung th bng quang
Nhiu ri lon tiu ha gy ra do ung th i trng v ung th bung trng.
2. Xm ln cc b
Ung th xm ln cc b ti cc c quan lm thay i hnh th hoc ri lon chc nng
ca c quan .
Da mu da cam khi ung th xm ln ti da.
Ni kh do ung th thanh qun xm ln ti dy thanh m
Nut kh lin quan n ung th thc qun hoc ung th vng u mt c
y bng kh tiu lin quan n ung th d dy

3
To bn lin quan n ung th i trc trng
Khi khi u xm ln cc t chc ln cn, c th quan st c mt s triu chng khc:
Ph n do chn p (cnh tay ph do xm ln ca ung th v, vim tc tnh mch do khi u
khung chu, bng bng do khi u bung trng, d dy hoc i trng, ph o khoc do hi chng
tnh mch ch, chn p tnh mch ch trn do u trung tht).
Kh th v xp phi trong ung th phi hoc di cn phi nng.
au do chn p dy thn kinh ngoi bin (au dy thn kinh ta do di cn xng hoc
xm ln khung chu).
Xm ln vo rn trong ung th bung trng (Syster Mary syndrome)
3. Hi chng xut huyt
Khi u tng trng ngy cng ln cn cc mch mu nui dng, s suy yu v h thng
mch mu dn n nui dng km gy hoi t, xut huyt ti khi u.
Ho ra mu trong ung th ph qun.
Nn ra mu v i cu phn en trong ung th d dy.
Tiu mu trong ung th bng quang, thn, niu qun hoc tin lit tuyn.
Xut tinh c mu trong ung th tin lit tuyn.
Chy mu trc trng trong ung th trc trng.
Xut huyt m o trong ung th c t cung.
Dch bng xut huyt trong ung th bung trng hoc ung th ng tiu ha.
Trn dch mng phi xut huyt lin quan ti ung th di cn mng phi.
Trc mi trng hp xut huyt i hi phi thm khm ton b tm ra nguyn
nhn trnh b st.

4
4. Hoi t
Hoi t thng xy ra do h thng mch mu nui dng khi u ngho nn. N thng
to ra:
Vt thng chm lin
Nhim trng khi u
Mi rt hi (rt c trng trong ung th u mt c v ung th ph khoa)
D t ng hoc d xy ra sau khi iu tr tia x
Lot hch dnh da hoi t rt hi
5. Di cn xa
Khong chng 15% bnh nhn ung th khi n khm c di cn
Di cn hch thng n (hch Troisier) pht hin c ung th ng tiu
ha, ung th vng chu; hch bn trong ung th b phn sinh dc ngoi; hch c trong ung th
vng tai mi hng.
Di cn vo da trong ung th v, ung th thn.
Di cn gan gy ra vng da, au gan.
Di cn phi (him khi gy ra kh th, thng pht hin c do chp Xquang phi kim
tra h thng).
Di cn no (thng gy nhc u, yu lit).
Di cn khc: di cn c th xy ra bt k c quan no.

5
II. THM KHM LM SNG
Thm khm lm sng mt cch ton din l cch tt nht t c chn on v xp
giai on bnh mt cch chnh xc.
Trc tin nn cho bnh nhn c thi gian h trnh by v tnh hnh bnh tt ca
h, thy thuc kin nhn lng nghe c thm thng tin v th hin s lich s v tn trng.
Nhng cu hi v lm sng nn chnh xc, kn o v thn thin. Mt cuc i thoi m l cch
u tin to c s tin tng v thn thin vi bnh nhn. N cho php nh gi nhng suy
ngh, nhng s hi, lo lng ca bnh nhn v tnh hnh bnh tt ca h, n cng cho php hiu r
hn hon cnh ca bnh nhn, gia nh v x hi.
Thm khm lm sng nn nh nhng trnh nhng thao tc gy au n khng cn
thit.
Trong mt s trng hp ung th sau khi khm lm sng mt cch k lng c th
chn on v xp giai on ung th. i vi mt s trng hp kh hoc bnh nhn khng cm
thy thoi mi, c th gy m ton than (c bit vi nhng ung th h sinh dc).
Thm khm lm sng khng k s gy lng ph thi gian v tin bc v nhng th
thut gy au n khng cn thit.
III.MT S TH THUT THM KHM LM SNG CHNH
Nhn v s nn v: i vi u v c th nhn thy u g ln, bin dng hnh th ca tuyn
v, mt cn i gia 2 v hoc da v mu da cam do ung th v xm ln da
G 2 ph trng hoc nghe pht hin trng dch mng phi
Thm khm khoang ming chn on v xp giai on ung th khoang ming.
Thm khm thanh qun vi gng Clarke chn on ung th thanh qun
6
S mt cch h thng cc vng hch c bit l hch c, hch nch , hch bn pht
hin cc ung th di cn n h thng hch tng ng.
S v g vo vng gan lch pht hin gan lch ln.
S nn bng pht hin u bng hoc bung trng.
Thm m o bng m vt pht hin ung th c t cung.
Thm trc trng pht hin ung th trc trng hoc nh gi tnh trng ca
dy chng rng trong ung th c t cung hoc thm st khi u vng tiu khung nh u bung
trng. i vi nam gii thm trc trng cn pht hin ung th tin lit tuyn.
S nn nh nhng v cn thn vng bu pht hin khi u tinh hon.
Thm khm thn kinh pht hin cc khi u di cn no.
IV. CN LM SNG
1. Xt nghim chn on hnh nh
Xt nghim chn on hnh nh thng c dng khng nh nhng tn thng nghi
ng qua thm khm lm sng v pht hin nhng thng tn mi, nh vy thay i c v nh
gi giai on bnh v kh nng iu tr.
1.1. Xquang phi
Phng php chp Xquang phi tuy n gin nhng rt hu ch chn on ung th
phi nguyn pht, ung th phi di cn, trn dch mng phi, kho st cc bin chng nhim trng
hoc x phi sau iu tr. Chp Xquang phi nn c s dng cng rng ri cng tt.
Mt s hnh nh c th thy c trn phim Xquang phi:
+ Hi chng ph nang hoc xp phi
+ Khi u n c hoc nhiu khi u phi

7
+ Vim tc bch mch dng ung th
+ Cc hc trong phi
+ Khi u trung tht
+ Trn dch mng phi
+ Trn kh mng phi
+ Cc di cn xng
+ Xquang xng
Xquang xng c th pht hin ung th nguyn pht xng hoc ung th di cn n
xng vi 3 hnh nh khc nhau:
Cc thng tn hy xng: bin mt mt vng cu trc ca xng (di cn t ung th
thn, phi, ung th u c v mt s ung th khc).
Thng tn dy xng: S dy ln mt vng cu trc xng (di cn t ung th v, tin
lit tuyn v ung th tuyn gip).
Th kt hp: Va hy v dy xng.
Xquang xng thng cho php chn on nhanh cc trng hp thng tn xng.
Mt s hnh nh Xquang xng pht hin di cn xng:
+ Hy xng cc xng t chi
+ Hy xng vng xng chu
+ Hy xng t sng
+ Hy xng s
+ Thng tn dy ln vng xng chu
+ Thng tn dy ln ca xng ct sng

8
+ Thng tn dy ln ca xng s
Hnh1: Chp X.Quang
1.2. Mammography
Mamography l xt nghim ang dn u trong chn on ung th v. Ngi ta hon
thin dn v mt k thut trong 10 nm qua v nhng tin b hn na ang trong qu trnh hon
thin nh k thut s ha.
Ngy nay ngi ta c th pht hin khi u nh hn 4mm ng knh (khi u tin lm sng)
vi nhng hnh nh c hiu v m , b khng r rng, khi m c hnh sao,vi ha vi th.
Sinh thit khi u c thc hin vi h thng c nh cho chn on rt tt v gii phu
bnh trc khi phu thut.
Hnh 2: Chp nh nh
9
Hnh 3: Kt qu chp nh nh
1.3.Siu m
Siu m c ng dng nhiu trong chn on ung th. Siu m pht hin c cc khi u
ca cc c quan nh khi u gan, u thn, khi u bung trng, u t cung v.v.
Siu m cn c th cho bit c tnh cht ca khi u: dng c hoc dng nang. Vi
nhng u d c tn s cao, siu m cn c th nh gi c mc xm ln ca ung th vo
t chc chung quanh (ung th d dy, ung th i trc trng...).
Chn on siu m d thc hin cc tuyn y t, gi c hp l, khng c hi. Tuy nhin
siu m kh thc hin i vi cc tng c khng kh v ph thuc vo kinh nghim ca ngi
c.
1.4. ng v phng x
ng v phng x l mt xt nghim thm d chc nng, cht lng hnh nh t ch hn
l thm d chc nng tht s. Tuy nhin, ung th khng ch l bnh l c th to ra bt thng
trn ng v phng x m cn mt s bnh l khc, do chng ta phi thn trng gii thch
nhng bt thng v nn i chiu vi bnh s lm sng ca bnh nhn.

10
1.5. X hnh xng
X hnh xng cho php pht hin di cn xng trc khi bt k triu chng Xquang no
xut hin v c th xem nh xt nghim sng lc pht hin di cn xng. Cht nh du c
tim vo l mt diphosphonate nh du vi 99Technetium. Ging nh Phosphorus ngi ta
quan st thy cht ny c nh nhng vng xng b thng tn: Vng callus xng nhng
xng b gy, bnh Paget ang tin trin, ung th di cn.
Tng liu phng x l rt thp (740MBq) khng gy nguy him g cho bnh nhn.
nhng vng xng b ung th di cn ta c th thy hnh nh tng c nh cht phng x
dng chm (punctiform hyperfixation). Tuy nhin hnh nh ny cng c th quan st c
nhng bnh l lnh tnh nh: vim khp, vim xng, di chng sau chn thng.
V nguyn tc ch c nhng ung th di cn c phn ng to xng mi c nh cht phng
x nh du, tuy nhin hu nh tt c cc vng hy xng u km theo qu trnh to xng ti
thiu do gy ra c nh cht ng v phng x nh du.
Nhng ung th di cn xng pht hin c bng x hnh xng thng l ung th v di
cn, ung th tin lit tuyn di cn v ung th tuyn gip. X hnh xng c th thay th cho chp
Xquang xung. Nhng tn thng xng nguyn pht cho nhng hnh nh r hn (v d nh
Sarcom Ewing).
Trong nhng trng hp nghi ng nh thoi ha khp, hoc cc bnh l chuyn ha v
xng nh bnh Paget chng ta c th chp Xquang xng hoc cng hng t lm r chn
on.
Hnh 4: X hnh xng

11
1.6. X hnh tuyn gip
X hnh tuyn gip rt c a chung pht ha ln nhng nhn lnh v loi b
nhng bnh l khc ca tuyn gip to ra do s tng th tch ca tuyn.
S dng Iode phng x nh du ph hp sinh l hn, tuy nhin thi gian bn hy ca
Iode phng x di (8 ngy) gy phin phc trong vn bo v an ton bc x. S dng
Technetium99 c a chung hn v cho nhng hnh nh r nt v nhn lnh v nhn nng v
theo di nhng nhn gip khng c.
Vi hnh nh x hnh tuyn gip chng ta c th phn bit mt s bnh l sau:
+ Nhn lnh: Khng c c nh Technetium v nn lm thm cc xt nghim khc
chn on.
+ Nhn nng: Nhn to ra nhiu hormone
- Bu gip a nhn
- Vim tuyn gip
- Bnh l ni tit ca tuyn gip: Basedow, suy gip.
Iode123 o mc bt Iode ca tuyn gip v theo di nhng trng hp iu tr
ung th tuyn gip bng iode phng x.
Hnh 5: X hnh tuyn gip

12
1.7. Min dch phng x hunh quang
K thut ny s dng 1 khng th c hiu kt hp vi 1 khng nguyn hoc 1 m c bit
c nh du vi 1 ng v phng x. Khng th c hiu khng b hp th bi khng nguyn
tun hon v nu c th khng lm ri lon thm cc th nghim v min dch ca khng nguyn.
K thut ny c s dng pht hin nhng vi di cn ca nhng bnh nhn iu tr
phu thut: Choriocarcinoma (HCG), di cn ca ung th tiu ha (ACE), ung th bung trng
(CA-125)v.v.
1.8. S dng ngv phng x trong lc m
Vi vic s dng u d phng x trong lc m, phu thut vin c th pht hin ra nhng
khi u khng th nhn thy c v thc hin c ct b hon ton (v d ung th tuyn gip ti
pht ti ch, ti pht ung th tiu ha vi th, d hch v tinh (sentinel) vt hch trong ung th.
1.9. PETScan
PETScan l mt k thut hnh nh v chc nng, lin quan trc tip chc nng ca mt c
quan hn l hnh thi ca c quan . Cng ging vi Scintigraphy, chp PETScan c thc
hin bng cch tim mt cht ng v phng x c nh du, thng thng ngi ta s dng 18-
Fluoro-Desoxy-Glucose (18FDG), cht ny khuch tn trong c th v c pht hin qua mt
mng hunh quang c bit: mt camera gn ng thi vo . Cht ng v phng x thng
dng c thi gian bn hy ngn (t vi pht ti vi gi). 18FDG ngy nay thng dng nht phc
v cho nhng nghin cu v lm sng. N l mt phn t glucose, mt nhm hydroxyl v tr 2
c thay bng mt nguyn t phng x fluor (18F). T bo ung th c s chuyn ha nng
ng hn t bo bmh thng, cn nhiu glucose hn t bo bnh thng. Khi18FDG xm
nhp vo trong t bo, n khng chuyn ha ging nh glucose bnh thng m li lu hn
trong t bo. Khi cc t bo ung th khng bit ha tin trin nhanh v nhn ln, chng s s
13
dng mt lng ln 18F-Glucose. S gia tng chuyn ha glucose ny cng c th gp trong mt
s bnh l nhim trng hoc vim hoc mt s loi t bo rt nng ng nh t bo no hoc t
bo c. Ngc li, mt vi khi u c tnh c th tiu th glucose thp, c bit l khi u c c
tnh thp hoc khi u hoi t. V vy c hiu ca PET-Scan khng phi l tuyt i.
Cc ch nh ca PETScan:
+ Ch nh trong ung th
+ PET dng chn on ung th, nh gi giai on v theo di trong iu tr
c bit trong bnh Hodgkin, Non-Hodgkinlypphoma v ung th phi.
+ Chn on cc khi u c. c bit hu ch pht hin cc khi u di cn, cc
khi u ti pht sau khi c ct b.
Cc ch nh khc ca PETScan:
+ Ch nh trong mt s bnh l ca no b
+ Bnh l tim mch, bnh l x mch, bnh l v mch mu.
+ Bnh l v tm thn kinh.
+ Bnh tm thn.
V dc hc: Nghin cu v tp trung v thi tr ca thuc.
Hnh 6: My chp PET-Scan Hnh 7:Chp PET

14
Hnh 7: Ung th gan Hnh 8: Ung th di cn xng
1.10 Chn on ni soi
Ni soi l phng php khm cc hc t nhin v mt s ni tng ca c th nh cc
phng tin quang hc. K thut ni soi ngy cng pht trin nhanh chng, hin i nh s tin
b ca k thut quang hc, cng ngh in t vi mch.
Ni soi c v tr rt quan trng trong chn on ung th d dy, ung th i trc trng, ung
th thc qun, ung th thanh qun, ung th ph qun, ung th bng quang .v.v.
Ni soi cho php tin hnh mt s th thut: sinh thit, ct polip, iu tr mt s tn thng,
bm thuc cn quang chp Xquang (chp ngc dng, chp ph qun). Ni soi can thip ang
pht trin nhanh chng v ang c p dng tin hnh cc phu thut nh ct bung trng,
ct ti mt, ct rut tha, vt hch chu, ct t cung v ct i trng. Tng lai phu thut ni soi
cn pht trin xa hn.
Hnh 10: Ni soi thp

15
1.11. Chp ct lp vi tnh ( CT-Scan)
Chp ct lp vi tnh l mt trong nhng phng tin chnh chn on ung th trong
hu ht tt c cc phn ca c th.
Nhng thng tn (u nguyn pht, hch nm nhng v tr su, u di cn) vi kch thc
>1cm l tng i d pht hin.
Lm tng cn quang bng cch tim cc cht cha Iodine lm tng s hin th mch
mu, thng tn do ung th d dng pht hin hn.
My chp ct lp hin i (Multislice) cho php ct cng nhng lt ct rt mng, vi s
nhim phng x ti thiu, thc hin trong mt thi gian rt ngn nh vy loi b nhng artifact
do c ng h hp lm gim kch thc ca nhng hnh nh bnh l c th pht hin c.
Chp ct lp vi tnh c th pht hin nhng thng tn tng i su nh vy c th dng
chp ct lp vi tnh hng dn chc sinh thit nhng khi u su trong c th.
Hin nay chp ct lp vi tnh l loi my tt nht xc nh th tch bia trong iu tr tia
x v tnh ton liu lng trc khi x tr.
Hnh 11: CT Scan

16
1.12. Chp cng hng t (Resonance magnetic imaging)
Chp cng hng t l phng php chn on hnh nh k thut cao, khng dng tia x
nn an ton cho bnh nhn. Nguyn l c bn l cc nguyn t trong c th sau khi t trong t
trng ca my s cng hng vi sng v tuyn v pht ra tn hiu.Tn hiu ny s c thu
nhn v x l vi tnh to ra hnh nh. y l dng sng in t khng gy tc hi cho ngi
chp.
Chp cng hng t cho nhng hnh nh rt r v bnh l thn kinh v xng. Ch nh
ca cng hng t hn ch hn ch nh ca CT-Scan. Tuy nhin chp cng hng t ang lin
tc tr nn nhanh v hiu qu hn, do ch nh ang tng ln v dn dn khc vi ch nh ca
CT-Scan. c bit nhiu nghin cu gn y ang c thc hin theo di nhng thay i u
tin c to ra do ha tr liu, x tr v d bo p ng lm sng vi iu tr.
Mt ch nh khc rt c quan tm l theo di nhng khi u sau x tr (c bit l ung
th v).
Hinh 12: MRI v

17
1.13. Mt s phng php chn on X.Quang khc
Phng php chp mch: trc y phng php ny t c s dng, hnh nh cho thy
s tng sinh mch rt mnh khi u (c bit trong nhng khi u thn v no). Chp mch cng
cn c s dng iu tr nh l nt mch hoc ha cht ng mch.
Hnh 13: Chp mch
2. Chn on sinh hc
Mt s xt nghim sinh hc c i hi chn on chnh xc bnh ung th. V d nh
o gi tr ca -HCG chn on ung th rau thai, thyroglobulin trong ung th tuyn gip.
Cc xt nghim sinh hc n gin khc l hu ch trong xp loi ung th (nghin cu v di
cn gan bng enzym gan (hepatic enzymology) hoc tnh trng ton thn trc khi bt tay vo
iu tr (cng thc mu, chc nng gan thn, oxymetry).
Nhng xt nghim khc nn c thc hin mt cch c h thng trong trng hp c thay
i v tnh trng ton thn, ri lon nc in gii, hoc kch thch (v d nh tng Calci mu
hoc tng Kali mu).
Cc xt nghim v cht ch im khi u (tumors markers) cng rt c quan tm chn
on v nh gi tin trin ca bnh hoc c tnh trong iu tr.

18
Cht ch im khi u l cht hin din trong mu, c th trong nc tiu hoc cc dch khc
ca cc bnh nhn ung th v khng c ngi kho mnh, do gi s xut hin ca ung
th.
Mt s cht ch im khi u chnh:
Cc protein ung th ca phi thai:(Oncofoetal proteins)
+ CEA: (Carcino embrionic antigen)
y l mt Glycoprotein hin din trong ng tiu ho, trong gan v tu ca bothai
gia thng th 2 v thng th 6 ca thai k. Chng c t l rt thp trong huyt thanh ca ngui
bnh thng. CEA c th tng cao trong ung th ng tiu ho, ung th v v ung th bung
trng. Tuy nhin n cng tng trong mt s bnh l lnh tnh nh x gan, thiu nng h hp v
nhng ngi nghin thuc l nng.
+ AFP(Alphafoeto-protein)
l mt 1-globulin c to ra bi gan, rut non v ti Yolk trong thi k bo thai.
Nng ca n tng cao trong ung th gan nguyn pht, trong ung th tinh hon dng non-
seminomatous hoc bung trng.
Hormones
+ HCG (Human Chorionic Gonadotropin)
Hormon ny c to ra trong thai k bi cc t bo syncytiotrophoblastic ca nhau thai.
Nng ca n tng cao trong ung th rau thai, ung th tinh hon dng non-seminomatous v
ung th bung trng.
+ Thyrocalcitonin
19
y l mt calcium ca tuyn gip iu ho hormon, n tng cao mt cch c bit trong
ung th tuyn gip th tu, ngoi ra n cn c tit ra mt cch lc ch trong ung th phi t
bo nh.
Enzymes
+ Acidic Prostatic Phosphatase
c tit ra bi cc t bo ca tin lit tuyn bnh thng, chng ch yu tng cao trong
di cn xng.
+ Alkaline phosphatase: nng trong mu ca n thng tng cao trong trng
hp di cn gan hoc di cn xng
+ LDH (Lactico-dehydrogenase)
y l mt enzyme ca c, nng ca n gia tng trong lymphoma, ung th tinh hon
v ung th phi do di cn.
+ PSA (Protate specific antigen)
N l mt glycoprotein c ngun gc t t bo tin lit tuyn. PSA gia tng mt cch c
hiu trong ung th tin lit tuyn v u x tin lit tuyn.
Mt s yu t tin lng mi ang ni ln t nhng nghin cu v sinh hc phn t v
ang lm thay i phng php kim tra i vi mt s loi ung th.
3. Chn on gii phu bnh
Chn on ung th lun lun i hi m sinh thit v xt nghim gii phu bnh (ngoi tr
trong giai on cui khi s iu tr tch cc khng cn ngha).
Ngoi tr mt s trng hp t gp, khi bt u ch nh iu tr trit cn phi c bng
chng gii phu bnh chn on l u c tnh (hoc t nht l chn on t bo hc). Mt s trng
20
hp nhim trng ko di, mt s u lnh tnh v mt vi bnh him gp c th nhm ln vi ung
th. Tuy nhin, nhng sai lm trong s dng x tr v ha tr i vi nhng trng hp nh vy
s gy nhiu bin chng nng n.
m bo mt cch chc chn chn on ung th trc khi ch nh iu tr phu thut,
x tr hoc iu tr ha cht bt buc phi c kt qu gii phu bnh.
3.1. Xt nghim t bo hc
Xt nghim t bo bong: Nhiu loi ung th gy ra tit dch, do chng ta c th ly
cht dch tit lm xt nghim t bo nh dch mng phi, dch mng bng, dch ty sng.
Chc ht khi u bng kim nh: l phng php chn on c gi tr v cho t l dng
tnh cao, c th thc hin i vi cc khi u nng v su trong c th. Vi nhng khi u su c
th chc di hng dn ca siu m.
Chn on t bo hc c nhiu u im nh nhanh, n gin, d thc hin, gi r. Tuy
nhin vn cn tn ti mt s m tnh sai v dng tnh sai.
3.2. Sinh thit trc phu thut
Nhng tin b v lm sng mi y t c ngy cng nhiu chn on gii phu bnh
trc khi phu thut vi s s dng ni soi pht hin khi u v sinh thit mt cch chnh xc.
Tng t cc k thut Xquang can thip c th sinh thit khi u bng kim.
Sau y l mt vi v d:
+ Ni soi thanh qun v sinh thit i vi ung th vng u mt c.
+ Ni soi ph qun vi u phi.
+ Ni soi d dy i vi u d dy.
+ Ni soi i trc trng i vi ung th i trc trng.

21
+ Soi c v thn t cung i vi ung th t cung.
+ Sinh thit u v, gan, thn, tin lit tuyn v cc u khc di s hng dn ca
siu m.
+ Sinh thit u v di s hng dn ca b phn c nh mammography.
3.3. Bnh phm m sinh thit
i vi mt s khi u nh sarcome phn mm, di cn phc mc do ung th bung trng
hoc khi u tinh hon, cc tc gi khuyn khng nn sinh thit do nguy c pht tn t bo ung th
ti c quan ln cn. Nghin cu i th bnh phm sinh thit nn:
- M t y , chi tit nhng mu bnh phm khc nhau m phu thut vin gi n.
- M t hnh nh i th (kch thc, mu sc, i th).
- Gii hn ca cc mc phu thut.
- M t tnh trng hch v lm tt c cc tiu bn v hch mt cch h thng.
- Ly mu ti mp ct lm tiu bn.
V. CHN ON GIAI ON
Chn on giai on l nh gi s xm ln v lan trng ca ung th bao gm nh gi
tnh trng ti ch, ti vng v tnh trng di cn xa. Chn on giai on nhm cc mc ch sau:
+ Gip la chn phc iu tr thch hp vi tng giai on bnh
+ Gip nh gi tin lng bnh.
+ Thun li cho cng tc nghin cu khoa hc, trao i thng tin, so snh v nh
gi cc phng php iu tr.

22
1. Phn loi TNM
T : U nguyn pht
To : Cha c du hiu u nguyn pht.
Tx : Cha nh gi c u nguyn pht
Tis : Ung th ti ch
T1-4 : U theo kch thc tng dn hoc mc xm ln ti ch ca u nguyn pht.
N : Hch vng
No : Cha c du hiu xm ln hch vng
Nx : Cha th nh gi c hch ti vng
N1-3 :Mc tng dn s xm ln hch ti vng.
M : Di cn xa
Mo : Cha c di cn xa
Mx : Cha nh gi c di cn
M1 : Di cn xa
23
CU HI KIM TRA NH GI
1. Nu cc xt nghim cn lm sang gip chn on ung th ?
2. Phng php nh gi phn loi giai on bnh ung th v ngha ?
TI LIU THAM KHO
I. TI LIU TING VIT
1. B Y t - Bnh vin K, 1999. Hng dn thc hnh chn on v iu tr ung th, nh xut
bn Y hc, trang 7-15.
2. i hc Y H Ni, 1999. Bi ging ung th hc, nh xut bn Y hc, trang 39-45.
3. UICC, 1995. Ung th hc lm sng, trang 189-207.
II. TI LIU TING ANH
1.Vincent T. De Vita, Principles & Practice of Oncology, Part 2.

1
Chuong VIII
CHT CH IM UNG TH
Mc tiu hc tp
1. Trnh by c tiu chun ca mt cht ch im khi u
2. Trnh by c cc ng dng lm sng cc cht ch im khi u
3. K c mt s cht ch im ca mt s loi ung th ch yu: V, i trng, bung trng,
tin lit tuyn, gan, gip trng, t bo mm v ung th nguyn bo nui.
I. T VN
Mi nm c hn 6 triu ngi cht v bnh ung th, 1.4 triu ca ung th mi c chn
on trn th gii. Theo nh gi ca T chc y t th gii (WHO), trong 20 mi nm ti cc
con s trn s gia tng v ln n 10 triu trng hp t vong v trn 16 triu ca ung th mi.
Vit Nam, bn cnh cc bnh nhim khun v suy dinh dng ngy cng gim dn, th
bnh ung th, bnh tim mch, tm thn ang c nguy c gia tng. Cc loi ung th hay gp
nc ta l ung th phi, d dy, v, gan, vm hng, i trc trng, hch bch huyt, t cung,
bung trng
Trong khi nhiu nc, chng trnh sng lc pht hin sm ung th t kt qu tt,
gp phn cha khi hn 50% bnh nhn ung th th nc ta a s ngi b ung th khi c
chn on giai on mun, t l cha khi bnh cn rt thp. C hi cha khi bnh ung th
chnh l lm sao pht hin sm ung th.
Cht ch im khi u c ngy cng c nhiu vai tr trong sng lc, nh gi gnh nng
ung th, tin lng bnh, theo di kt qu iu tr v d bo ti pht.

2
II. KHI NIM V CHT CH IM KHI U
1. nh ngha
Cc cht ch im ung th (CCUT) l nhng phn t t nhin c trong huyt thanh,
huyt tng v cc dch khc trong c th, hoc cc mu th ly t m ti hoc m nhng
paraffin xc nh s hin hu ca ung th, nh gi tin lng bnh nhn hoc theo di s
p ng ca bnh vi phng php iu tr.
Cht ch im ung th cn c tm thy bn trong t bo c t bo cht v nhn v
nhng cht ny lin kt vi mng t bo. CCUT thng c bn cht protein, xut hin trong
mu, nc tiu, trong cc cht dch, m ca c th ngi bnh v thng khng xut hin r
ngi kho mnh. S thay i nng ca CCUT c lin quan mt cch chc chn ti s pht
trin cc khi u c tnh ca c th .
2. Phn loi
C hai loi ch im khi u chnh
2.1. Ch im t bo: L cc khng nguyn tp trung trn b mt ca mng t bo nh trong bnh
Leucemie, cc ni tit t v c quan th cm ni tit trong ung th v
2.2. Ch im dch th: L nhng cht xut hin tp trung trong huyt thanh, nc tiu hoc cc
dch khc ca c th. Cc cht ny c tng hp v bi tit t cc m ca khi u, c gii
phng nh s phn hy t bo u hoc c to thnh nh l s phn ng ca c th i vi khi
u.
3
2.3. Phn loi cht ch im theo bn cht v cc ung th lin quan chnh
Bng 1. Phn loi CCUT theo bn cht v cc ch nh chnh
Cc loi cht ch im ung th Bnh lin quan chnh
Cc enzyme
Alkaline phosphastase UT xng, gan v nhau thai
Lactate dehydrogenase (LDH) U lymph c, UT mu
Neuron specific antigen UT phi TB nh, u nguyn bo thn kinh
Prostatic Acid Phosphastase UT tin lit tuyn
Prostatic Specific Antigen (PSA) UT tin lit tuyn
Cc hormone
Adrenocorticotrophic Hormone (ACTH) UT phi TB nh
Calcitonin UT gip th ty
Human chorionic gonadotrophin Ung th nhau thai
Khng nguyn thai ung th
-Fetoprotein UT gan nguyn pht
Carcinoembryonic antigen (CEA) UT i trc trng
Khng nguyn carbohydrate
CA 15-3 UT v
CA 27-29 UT v (ti pht)
CA 125 UT bung trng v ni mc t cung

4
Receptor v cc cht ch im khc
Estrogen v Progesteron UT v
Immunoglobulin a u ty, u lymph c
Microglobulin a u ty, u lymph c t bo B
Cc cht ch im gen
Cc gen sinh UT:
t bin gen N-ras U nguyn bo thn kinh, UT mu th ty
t bin gen K-ras UT ty, UT my v u lymph c
Khuych i gen c-erb B-2 UT v
Chuyn on c-myc U lymph c TB B v T
Cc gen p ch ung th
Gen nguyn bo vng mc mt U nguyn bo vng mc mt
Gen P53 UT v, i trng
Gen BRCA 1 v 2 UT v
Gen WT1 U Wilm
Cc khng nguyn nhm mu
CA 19-9 UT i trc trng, UT ty
CA 72-4 Cc UT tiu ha, bung trng

5
III. TIU CHUN CA CC CHT CH IM KHI U
Cht ch im khi UT l tng dng chn on ung th, gip sng lc, theo di din
tin UT. V vy CCUT l tng cn c cc tiu chun sau:
+ C nhy v c hiu cao.
+ Nng thay i theo giai on bnh (phn nh c gnh nng ca ung th).
+ Tin lng c ung th.
+ D on ti pht.
Khi nim nhy v c hiu ca CCKUT:
+ c hiu: c hiu ca mt CCUT l t l % ngi khe mnh hoc c
bnh lnh tnh trong kt qu xt nghim ca h c kt qu m tnh mt cch chnh xc.
+ nhy: nhy ca mt CCUT l t l % ngi bnh dng tnh chnh xc
vi CCUT.
nhy v c hiu cao c ngha:
+ C th pht hin rt sm t khi ch c vi t bo ung th xut hin.
+ c trng cho c quan c u.
+ Tng quan vi giai on ca khi u.
+ C gi tr d on tin cy.
Hin nay, rt tic cha c cht ch im khi u l tng c y 100% tiu chun v
c hiu, tin cy chc chn, tnh c trng c quan v chn on chnh xc giai on bnh.
Tuy nhin, mt loi ch im khi u c nhng gi tr trn cc tiu chun khc nhau v khi phi
hp 2 hay nhiu th nghim li c thm nhiu gi tr mi b sung ln nhau. PSA, PAP (Prostatic
Acide Phosphatase) v Thyroglobulin l nhng cht ch im c hiu cho c quan c u.

6
Nhiu cht ch im khi u c xem l c tng quan vi giai on pht trin ca u, c
nng tng cao nhng giai on mun. Tuy kh xc nh chc chn khi u ang giai on
no v i khi c s trng cho gia cc loi.
Tuy nhin, gi tr tin lng ca mt s cht ch im rt r v thng gn vi qu trnh
tin trin v kt qu iu tr. V d: hm lng CEA trc m ung th i trc trng, 2
Microglobulin trong u lympho c khng Hodgkin v bnh a u ty.
CA 125 trong ung th bung trng cng cao th tin lng cng xu, kh nng ti pht, di
cn cng nhiu
nhy cm v c hiu ca mt cht ch im c tnh bng cng thc sau:
S ln dng tnh (+) tht
nhy =-------------------------------------------------
S ln (+) tht + S ln m tnh ( - ) gi
S ln m tnh ( - ) gi
c hiu =----------------------------------------
S ln (-) tht + S ln ( + ) gi
Mt s tiu chun quan trng khc l gi tr d on ca cc cht ch im khi u. Gi tr
d on dng tnh c ngha c kh nng c mt khi ung th no xut hin m c th s
dng 1 phc hp cc nghim php kim tra pht hin c.
Gi tr d on m tnh ch ra rng khng th c mt loi ung th no xut hin nu
kt qu xt nghim m tnh.
7
S ln m tnh (-) tht
Gi tr d on (-) = -------------------------------------
S ln (-) tht + S ln (-) gi
S ln dng tnh (+) tht
Gi tr d on (+) = ---------------------------------------
S ln (+) tht + S ln (+) gi
IV. NG DNG LM SNG CA CHT CH IM KHI U
1. Sng lc
a s cc cht ch im khi u hin nay khng c khuyn co dng trong sng lc pht
hin sm ung th do c hiu v nhy thp. Tuy nhin c th dng sng lc cho nhng
nhm ngi c nguy c cao. V d: -FP i vi bnh nhn x gan c nhiu nguy c mc ung
th gan nguyn pht, Calcitonin i vi nhm ngi trong nhng gia nh c nhiu ngi ung
th tuyn gip.
2. Chn on ban u
Thng thng ng dng ny t c s dng v thiu c hiu v nhy. Kt qu m
tnh hay dng tnh cng khng c gi tr quyt nh chc chn c hay khng c ung th.
3. Xc nh c quan c khi u
PSA hoc PAP tng cao trong bnh u tuyn tin lit, thyroglobulin tng trong ung th
tuyn gip th ty. Sau phu thut ct b tuyn gip ton b nu thyroglobulin tng tr li chng
t bnh ti pht.
8
4. Xc nh giai on
Mt vi cht ch im khi u c nng lin quan n giai on bnh, phn nh c
gnh nng ung th. V d: CEA trong ung th i trc trng, CA 125 trong ung th biu m
bung trng
5. Tin lng
Mt s cht ch im khi u c gi tr tin lng: tp trung cao c gi tr tin lng
xu. o gi tr trc v sau iu tr s c th bit tin lng ca bnh. V d: CEA, CA 125, CA
15-3, 2-Microglobulin
6. Kim tra kt qu iu tr v theo di
l ch nh quan trng nht ca cht ch im khi u, l cch kim tra sm v c hiu
qu kt qu iu tr bng phu thut, tia x, ho cht
- Cc ch im khi u tr v mc bnh thng chng t ly i ht hoc thoi lui
ton b khi u.
- Tn ti dai dng mc bnh l hoc tng ln sau thi gian ngn xung dc
chng t bnh vn cn tn ti hoc xut hin di cn.
- Tng ln tr li sau khi n nh mc bnh thng (v d sau phu thut),
chng t bnh ti pht.

9
Bng 2. Tm tt gi tr p dng lm sng ca mt s CCUT chnh:
UT nguyn Theo di sau iu tr Theo di p ng
CCUT pht Sng lc Chn on u tin vi iu tr
CA 27.29 UT v Khng Khng Theo di cc BN c nguy Hu ch
c ti pht cao. nh gi
lng CA 27.29 mi 4 n 6
thng
CEA UT i trc Khng Khng BN c nguy c ti pht cao Rt hu ch
trng cn nh gi CEA mi 2 n
3 thng trong t nht 2 nm
CA 19-9 UT ty, UT Khng Gi chn Khng Hu ch
ng mt on UT ty
AFP HCC, u t Khng UT khng r BN UT t bo mm khng Cn thit trong UT
bo mm nguyn pht phi seminome, XN AFP v TB mm khng
khng phi bit ha km; -hCG mi 1 n 2 thng phi seminom. Rt
seminome BN x gan trong nm u, sau mi 3 c gi tr theo di
km khi u thng vo nm th 2 ri XN sau iu tr HCC
gan th dn
10
Khi u t bo Khng UT khng r Khi u t bo mm khng Thit yu i vi
-hCG mm non nguyn pht phi seminom; UT l nui bnh nhn u t bo
seminom, bit ha km, thai nghn, o mc -hCG mm khng
bnh l phi bnh l phi mi thng/ln trong 6 n 12 seminom hoc
thai thai thng bnh l nui thai
nghn iu tr.
CA 125 UT bung Khng Gi chn Xt nghim mi 3 thng Rt hu ch
trng on khi u trong 2 nm u sau thc
vng chu hin tha hn.
BN mn kinh,
bng c tnh
ph n b UT
khng r
nguyn pht.
PSA UT tin lit C UT khng r Xt nghim PSA mi 6 Rt hu ch
tuyn nguyn pht, thng trong 5 nm u sau
scan xng c xt nghim hng nm.
tn thng Nu PSA tng tr li sau ct
rng v khi u b tin lit tuyn hoc sau
tin lit tuyn iu tr tia x lun cho thy
ti pht.
11
Bng 3. Cht ch im UT nguyn pht, th pht v ti pht
2 Microglobulin
PSA ton phn
Thyroglobulin
CYFRA 21-1
Loi Ung th
PSA t do
CA 15-3
CA19-9
CA72-4
CA 125
Feritin
HCG
CEA
NSE
AFP
i trng

Ty

D Dy

Thc qun

Gan
ng mt
Bung trng

C t cung

Nguyn bo nui

UT phi TB nh

UT phi khng phi

TB nh
Tin lit tuyn

Bng quang

Tuyn gip

12
U lymph c

UT + thiu mu

UT nguyn bo

: cc cht ch du nguyn pht : cc cht ch du th pht : cc cht ch du ti pht
Ch thch: CEA: Carcinoma Embryonic Antigen.
FP: foetoprotein.
HCG: Human Chorionic Gonadotropin.
CA 15-3: Cancer Antigen 15-3.
CA 19.9: Cancer Antigen 19.9
CA 72-4: Cancer Antigen 72-4
CA 125: Cancer Antigen 125
PSA: Prostate Specific Antigen
PAP: Prostate Acid Phosphatase
2 Microglobulin: Beta 2 Microglobulin
NSE: Neuron Specific Enolase

13
CU HI KIM TRA NH GI
1. Trnh by cc tiu chun ca mt cht ch im khi u v cc ng dng lm sng ca cht ch
im khi u ?
2. Nu mt s cht ch im ca cc s loi ung th sau: V, i trng, bung trng, tin lit
tuyn, gan, gip trng, t bo mm v ung th nguyn bo nui ?
TI LIU THAM KHO
I. TI LIU TING VIT
1. Nguyn B c. 1999. Bi ging ung th hc. Nh xut bn Y hc. Trang 58-64.
2. Nguyn Th Khnh, Phm T Dng. 2002. Xt nghim s dng trong lm sng. Nh xut
bn Y hc.
3. Richard D. Love, 1995. Cm nang ung bu hc lm sng (Ti liu dch t Manual of Clinical
Oncology).. Nh xut bn Y hc, Trang 160-184
II. TI LIU TING ANH
1. David N. Lewin. 2000. Laboratory Medicine. Trang: 400 408.
2. Greg L. Perkins, Evan D. Later, 2003. Serum Tumor Markers.

1
Chng IX
IU TR PHU THUT BNH UNG TH
Mc tiu hc tp
1. Nm c cc nguyn tc ca iu tr phu thut trong ung th.
2. K c cc loi phu thut trong iu tr bnh ung th ?
iu tr phu thut ung th bt u t thi c i v mt thi gian di phu thut l
phng php duy nht iu tr ung th. n nay phu thut vn l hn tng trong cc
phng php iu tr ung th hin i. Theo cc tc gi Timothy.J.Eberlein hoc nhm tc gi
John M.Daly th ngy nay c khong 60% n 75% bnh nhn ung th c iu tr bng phu
thut v cc k thut ngoi khoa cn c s dng chn on, xp giai on cho hn 90% cc
bnh ung th.
Nhng tin b vt bc trong nhng nm gn y v k thut m, gy m, hi sc ci
thin mt cch ng k hiu qu ca phu thut. Ngoi ra, nhng nghin cu v kt qu lm sng
gn y cho thy phi hp phu thut vi cc phng php iu tr khc lm tng hiu qu ca
iu tr.
I. S LC LCH S
Phu thut ung th pht trin theo thi gian cng vi vic ng dng nhng thnh tu trong lnh
vc gy m hi sc, chng ta im qua vi mc lch s quan trng sau:
- Albert Theodore Billroth ( 1829-1894 ) thc hin ln u tin ct d dy, ct thanh qun
v thc qun.
2
- William Stewart Halsted (1852- 1922) ra nguyn tc ct b ung th thnh mt khi
c bit l trong phu thut ct b ton b v trit cn thnh mt khi v sau phu thut ny
mang tn ng.
- Hugh Young (1870- 1945) thc hin phu thut ct trit cn ung th tin lit tuyn.
- Enrst Wertheim (1864- 1920) thc hin phu thut ct t cung trit cn nm 1904.
- William.E.Miles (1869- 1947) thc hin ct b trc trng trit cn qua ng bng-tng
sinh mn nm 1906.
- Evats Graham (1833- 1957) thc hin phu thut ct phi trit cn thnh cng do ung
th phi nm 1933.
Ngy nay nhng k thut phu thut hin i pht trin mt cch nhanh chng nh vi
phu thut, phu thut ni soi s ha hn nhiu thnh cng trong phu thut ung th.
II. CC NGUYN TC CA PHU THUT UNG TH
1. Tho lun a phng thc iu tr trc khi phu thut
Ngoi tr nhng trng hp cp cu, bc s phu thut nn hi chn vi cc thnh vin
khc nh bc s x tr, bc s ho tr thng nht mt liu trnh iu tr cho mi bnh nhn.
2. C kt qu chn on gii phu bnh trc khi phu thut
y l quan im quan trng nht trong phu thut ung th: phu thut vin phi bit v
loi m bnh hc ca khi u trc khi thc hin phu thut ct b.
Trong ung th v, phi c kt qu sinh thit bng kim hoc sinh thit m chng t tnh
cht c tnh ca nhng hnh nh nghi ng trn phim chp nh nh. i vi ung th u c v mt
s loi ung th khc nh d dy, phi, i trng thc hin sinh thit qua ni soi trc khi phu
thut.
3
Trong nhng trng hp hn hu khng th sinh thit c c th thc hin phu thut
thm d. Trong nhng trng hp phu thut vin nn kt hp vi bc s gii phu bnh
thc hin sinh thit tc th trc khi quyt nh ct b.
3. Vit bn tng trnh v phu thut
Bn tng trnh v phu thut l ti liu quan trng nht trong h s ung th ca bnh
nhn. Bng tng trnh nn vit ngay sau khi m xong v nn m t chi tit mt s ni dung sau:
+ M t chi tit nhng thng tn quan st c:
+ Kch thc ca khi u nguyn pht
+ V tr chnh xc ca khi u
+ Lan trn ti cc cu trc ln cn
+Dnh ca khi u vi c quan ln cn
+ Kch thc v v tr ca cc hch di cn
M t r rng cc thao tc thc hin trong phu thut
+ Nhng thao tc thc hin v khng thc hin do k thut hoc l do khc.
+ V tr chnh xc ca clip li trn din khi u ct b.
+ M t chnh xc khi u li sau phu thut, cc mu bnh phm c ly
lm xt nghim.
+ Cc mu bnh phm c bit lm xt nghim sinh hc phn t.
M t chnh xc hon thnh phu thut
+ M t r rng phu thut c hon thnh.
+ M t bn cht ung th ca phu thut (cc b mp ct).
+ V tr chnh xc v m t khi u li sau phu thut.

4
Chun b bnh phm xt nghim gii phu bnh
+ Ly cc b ng bnh phm ring cho tng mu bnh phm khc nhau
+ Cc mp ct ca bnh phm phi c nh du.
+ Mu bnh phm phi nguyn vn, khng nn ct nh ra.
+ Mu bnh phm phi c b vo dung dch bo qun (formalin hoc dung dch
mi khc) nu phi chuyn bnh phm trong thi gian di.
+ Mu bnh phm cho cc xt nghim sinh hc phn t phi c chuyn i ngay
v bo qun theo ch ring.
+ Mu bnh phm cho nui cy m phi bo qun trong mi trng c bit.
S chun b bnh phm cn thn nh vy gip cho cc nh gii phu bnh thc hin c
xt nghim c cht lng v tr li mt cch chnh xc kt qu gii phu bnh v cc nh sinh
hc thc hin cc xt nghim sinh hc chun mc hn.
III. CC LOI PHU THUT UNG TH
1. Phu thut trit cn
Quan nim ct b t chc ung th thnh mt khi
Trn quan nim t chc ung th thng xm ln, pht trin ra t chc chung quanh,
khng xc nh r ranh gii ca khi u nn phu thut trit cn l phi ct b t chc ung th
thnh mt khi gm: khi u, c quan mang khi u, t chc lin kt chung quanh khi u cng vi
h thng bch huyt v hch bch huyt vng. Kh nng di cn hch vng l rt ln, do nn
phu thut vt cc hch v tinh ngay c khi v i th n cha c du hiu xm ln. Ti thiu nn
vt hch mc I v ly ht t chc lin kt nm gia khong u v hch.

5
Trong nhng trng hp kh khn c th thc hin ct b gii hn, ct b hon ton khi
u mt cch rng ri n gii hn b khi u khng tm thy t bo ung th. Nh vy phu thut
vin phi lin h vi bc s gii phu bnh trong lc m s lm xt nghim sinh thit tc th
xc nh xem b mp ct sch t bo ung th cha.
2. Mt s phu thut trit cn chnh
i vi ung th tiu ho mt s phu thut trit cn c thc hin:
- Ct ton b thc qun trong ung th thc qun.
- Ct ton b d dy hoc ct rng ri d dy km vt ton b hch trong ung th
d dy.
- Ct na i trng phi trong ung th manh trng km theo vt hch cho n gc
ng mch i trng.
i vi ung th v: ct b ton b tuyn v km theo vt hch nch.
i vi ung th h sinh dc: ct b t cung ton phn km theo vt hch chu hai bn l
phu thut chun i vi ung th c t cung v ung th thn t cung.
Trong niu hc, i vi ung th tinh hon ct b ung th tinh hon qua ng bn, gm
buc thng tinh ln cao trnh pht tn t bo ung th.
i vi ung th bng quang nam gii, ct bng quang ton phn km ti to li bng
quang.
3. Nhng hn ch ca ct b ung th thnh mt khi
Quan nim ct b ung th thnh mt khi i khi kh p dng trong mt s trng hp,
do gii thch nhiu tht bi trong phu thut.

6
i vi ung th bung trng, v lm sng t chc ung th thng xm ln lan to phc
mc lm cho phu thut rt kh khn. Mt s phu thut vin ngh ct b hon ton phc mc,
tuy nhin phu thut ny gy nhiu bin chng v ngi ta t b .
Vi ung th tin lit tuyn, ct b ton b tin lit tuyn l phu thut trit cn, tuy nhin
phu thut vin mun bo tn dy thn kinh cng dng v tiu tin t ch nn phi thc hin
phu thut gii hn v iu tr x tr hu phu h tr.
Trong phu thut ung th vng u c gii hn cc mc gii phu rt gn gii hn thng
tn cn ct b, do khng cho php phu thut rng ri, cn b sung x tr sau phu thut.
4. Vai tr ca vt hch trong phu thut ung th
Mc ch ca vt hch mt cch h thng trong phu thut ung th l xc nh kh
nng tin trin ca ung th. Hch b xm ln l mt yu t tin lng ng tin cy: cng nhiu
hch xm ln tin lng cng xu.
Vt hch c thc hin bt u t khi u v vt theo tng trm hch t mc mt n cc
mc k tip. Di cn hch cng xy ra tun t, hin tng nhy cc l rt him.
Nhn chung, vt hch nn quan tm ti trm hch u tin, bi v qua khi trm hch ny
ung th xem nh c kh nng di cn. Nhiu nghin cu cho thy phu thut vt cc hch b di
cn hu nh khng lm thay i tin lng ca bnh nhng cng trnh c chn p, au khi
hch ln.
trnh nhng bin chng trong vt hch rng ri (nh ph bch mch chi trn v chi
di), nhiu nghin cu c thc hin vi nhng khi u nh, thng nhng u ny khng c
di cn hch, nh vy vt hch tr nn v dng (v d nh khi u v nh hn 5mm, ung th c
t cung xm ln vi th).
7
Trong phu thut ung th v nhiu nghin cu v hch gc (sentinel node), l hch trm
hch u tin c ch nhiu nht. Ngi ta dng k thut pht hin hch bng cch tim
cht mu (Evans Blue) hoc bng ng v phng x chung quang khi u, cht mu i theo h
bch huyt v nhum xanh hch gc gip phu thut vin d nhn bit bc hch lm sinh thit.
Nu tim cht ng v phng x ngi ta s dng u d phng x pht hin hch gc.
5. Phu thut ung th gii hn
Phu thut ct b rng ri ung th thnh mt khi cng gy ra nhiu tranh ci, bi v
theo quan st ngay c khi khi u ang cn ti ch, thc s c di cn m lm sng cha pht
hin c, do phu thut ct b trit cn khng lm thay i c tin lng. V d v ung
th v:
Cc nghin cu ngu nhin chng minh rng phu thut bo tn bng ct b khi u v
rng ri (mammary lumpectomy) n b mp ct khng cn t bo ung th km x tr v sau m
cng c kt qu ging nh ct b ton b v trit cn. Yu t tin lng chnh l tnh trng ca
hch v tinh. ng knh ca khi u c ct b khng lm thay i nguy c di cn xa.
Khi hch nch dng tnh hoc khi u c bit ho km, iu tr ho tr h tr hoc ni
tit ng vai tr quan trng trong liu trnh iu tr.
6. Phu thut gim th tch khi u
i vi mt vi loi ung th, mong mun ca phu thut vin l phu thut lm gim ti
a th tch ca khi u trc khi s dng cc phng php iu tr khc nh x tr hoc ho cht.
in hnh l trong ung th bung trng v lymphom Burkitt.

8
7. Phu thut d phng
Cng ngy ngi ta cng xc nh c thm nhng bnh l m vi thi gian s pht trin
thnh ung th. iu tr khi nhng bnh l ny bng nhiu phng php trong phu thut l
mt phng php chnh s loi b c nguy c mc ung th nh:
- H tinh hon lc ch d phng ung th tinh hon
- Ct b i trng trong vim lot i trng mn, bnh a polip i trng trong d
phng ung th i trng.
- Ct b polyp i trc trng trc tui 20, phu thut ct tn thng vim i trc
trng chy mu.
- Ct tuyn gip phng nga ung th tuyn gip th ty bnh nhn a u tuyn
ni tit MEN II.
- Ct b rng ri trong bnh l bch sn d phng carcinoma t bo gai.
- Ct b tuyn v hoc bung trng do nhng thng tn lnh bt thng nhng
gia nh c t l ung th v v bung trng cao.
8. Phu thut chn on bnh ung th
Phu thut chn on ch yu l thm d ly mu bnh phm lm xt nghim m bnh
hc. Gm cc loi: chc ht sinh thit, khot chp hoc phu thut ct b sinh thit. Chn on
chnh xc bng m bnh hc l c s lp k hoch iu tr ung th mt cch chnh xc v hiu
qu.
Chc ht bng kim nh xt nghim t bo hc.
Sinh thit bng kim ln (True-cut, Vim- Silverman, Franklin).
M sinh thit: C th ly trn khi u hoc ct mt phn lm xt nghim m bnh hc.

9
M thm d i vi nhng khi u bng v d nh u mc treo rut, u c thnh rut v.v.
Mt s lu trong phu thut chn on:
- Ly mt mu m in hnh vi c b m bnh thng.
- Khng sinh thit vo m hoi t.
- Trnh gieo cy vo m bnh thng ln cn.
- ng rch da sinh thit phi nm trong phn m m s c ct b bi mt
phu thut iu tr tn gc tip theo sau.
- Cung cp nhng thng tin lm sng cn thit cho nh gii phu bnh.
9. Phu thut nh gi tin trin ca ung th
i vi mt s khi u, phu thut l mt cng c rt quan trng nh gi p ng ca
khi u i vi ho tr liu. Mt trong nhng in hnh l phu thut thm st ln hai (second look
laparotomy) trong ung th bung trng. Phu thut ny c thc hin mt cch h thng
nh ga p ng ca ho tr v kt thc iu tr. Trong thc t ngi ta chng minh rng
phu thut nh vy khng thay i c thi gian sng thm ca bnh nhn, do phu thut m
bng thm st ln 2 ngy nay ch cn thc hin trong nghin cu lm sng.
Ngy nay ngi ta s dng Pet-Scan chn on trc khi phu thut, nh vy trnh
c phu thut khng cn thit.
10. Phu thut i vi nhng khi u ti pht v di cn
10.1.Phu thut khi u ti pht
Mt s khi u ti pht xy ra sau iu tr bo tn th nn thc hin phu thut trit cn
- i vi ung th u c: ct ton b thanh qun sau iu tr bo tn ti pht.

10
- Trong mt s ung th ph khoa c iu tr bng x tr n thun ti pht: ct
rng ri vng chu i khi kh thi.
- i vi ung th v m ct u bo tn v (lumpectomy): khi ti pht mun xy
ra, ngi ta ngh ct b ton b v.
Tuy nhin trong mt s trng hp khi u ti pht sau iu tr tia x, khng th ct b
rng ri c th c th ct b khi u tm thi lm sch, gim au v gim nh triu chng.
10.2.Phu thut nhng khi u di cn
Trong qu kh ngi ta khng thc hin phu thut i vi cc khi u di cn. Di cn xy
ra trong thng u hoc nm u sau phu thut chng t rng di cn c trong thi gian phu
thut, tuy nhin khi u qu nh chng ta khng th pht hin c bng cc phng php thng
thng.
Nhng nm gn y cc kin thc v sinh hc trong ung th dn hon thin v ngi ta
ngh ct b nhng khi u di cn vi nhng iu kin sau:
- Khi khi u nguyn pht n nh hoc bin mt
- Khi u ti pht xy ra phi cch ln phu thut u tin mt thi gian di, ti thiu
l 2 nm tr ln.
- Khi di cn l mt n c (c th 2-3 nhng nm chung mt ch).
- Khi phu thut tng i n gin khng nguy him n tnh mng bnh nhn.
11. Phu thut gim nh triu chng
Phu thut i vi di cn xng
Gy xng bnh l (do di cn) s c kt hp xng nh gy xng bnh thng lm
cho gy c bt ng tt. Mc khc di cn xng xy ra khng c ngha l bnh nhn sp t

11
vong, n bo hiu bnh nhn ri vo giai on suy kit (nm lit gng, nguy c l lot cc
im t, mt kh nng t phc v). iu tr tch cc s gip bnh nhn c th phc hi c vn
ng v trnh c cc bin chng do nm lu.
Cc tc gi khuyn nn phu thut phc hi nhanh chng gy xng bnh l khi c th
hi phc li vn ng cho bnh nhn. Mt s trng hp in hnh sau:
- Gy c xng i do di cn xng: phu thut thay khp hng
- Gy thn xng i: ng inh ni tu
- Xp ct sng: phu thut lm vng ct sng (corporeal cementoplasty)
S hin din ca cc khp gi l khng chng ch nh trong x tr.
Trong trng hp di cn ct sng c chn p tu (xut hin lit) phi can thip phu thut
sm trc 24 gi, sau 24 gi xut hin thng tn mch mu do chn p tu. Nh vy chn on
chn p tu nn c iu tr cp cu v nn chuyn nhanh bnh nhn n phu thut vin m
gii phng chn p v c nh. iu tr tia x b sung cng c ch.
12. Phu thut tm thi
Phu thut tm thi c thc hin khi khi u gy ra tc nghn ng h hp, tiu ho
hoc tit niu.
Mt s phu thut in hnh:
- M kh qun (i khi phi thc hin cp cu) i vi ung th u c hoc ung
th tuyn gip.
- Lm hu mn nhn to trong trng hp ung th ng tiu ho hoc bung
trng.
- M thng d dy nui dng i vi ung th thc qun hoc ung th u c.

12
- M thng niu qun hoc bng quang trong trng hp ung th tin lit tuyn
hoc ung th ph khoa.
- t shunts ni s trong trng hp tng p lc ni s.
trnh nhng chn tng v mt tm l cho bnh nhn trc khi phu thut, phu thut
vin nn gii thch r cho bnh nhn v gia nh. Phu thut khng nn thc hin qu mun khi
cc chc nng ca c th b thng tn, cng khng nn thc hin qu sm bnh nhn kh
chp nhn.
13. Phu thut lm sch
Phu thut lm sch cng c ngh thc hin khng phi mc ch iu tr m ch
lm cho bnh nhn thoi mi hn.
Cc khi u hoi t khng ch gy ra au, n cn c mi hi, chy mu, bn thu kh nhn
lm cho bnh nhn v gia nh khng thoi mi. Ch nh ct b u hoi t em li s thoi mi
cho ngi bnh.V du nh ct b v i vi nhng ung th v l lot ra da, ct b nhng ung
th rut non mc d c di cn gan, ct b cc ng d.
14. Phu thut v ni tit
Phu thut v ni tit l phu thut ct b mt tuyn ni tit m cht tit ca n lin quan
n s pht trin ca khi u. Trong thc hnh ch c 2 loi ung th thng hay thc hin:
- Ct b 2 bung trng trong ung th v c lin quan n ni tit nhng ph n
cn kinh nguyt.
- Ct b 2 tinh hon nhng bnh nhn ung th tin lit tuyn.

13
15. Phu thut to hnh
Hu ht cc phu thut ct b trong ngoi khoa u nhm vo mc ch bo tn chc
nng cc c quan ca c th khi c th c. Tuy nhin trong phu thut ung th, m bo
mp ct an ton phi ct b rng ri khi u, nh vy phu thut ti to li tr nn l mt phng
din rt quan trng trong phc hi iu tr cho bnh nhn. i khi phu thut to hnh c thc
hin cng mt lc vi phu thut ct b.
- Ti lp lu thng tiu ho (rut, thc qun).
- To hnh bng quang bng cc quai rut trong ct bng quang ton b.
- To hnh thanh qun bng Prosthesis trong ct thanh qun ton phn.
- To hnh v sau phu thut ct v.
- Lm prosthesis tinh hon sau ct b tinh hon.
- Lm li mt gi sau phu thut ct b nhn cu.
Trong mt s trng hp phu thut to hnh c thc hin sau khi hon tt cc iu
tr h tr:
- To hnh v sau khi iu tr ho tr hoc x tr h tr sau phu thut.
- Trong ung th xng, to hnh li xng sau khi iu tr ho tr
Cui cng, mt s phu thut to hnh nhm mc ch sa cha li cc di chng do iu tr:
- To hnh li xng hm sau khi xng hm b hoi t do x tr.
- To hnh phc tp sau cc phu thut rng ri vng u c.

14
16. Phu thut gim au
Phu thut gim au c ch nh trong nhng trng hp c bit khi m cc thuc
gim au iu tr khng c hiu qu. Chng l cc th thut gim au c thc hin trong
phng m:
- Kch thch thn kinh qua da
- Gy t qua tu sng
- Trong mt s t trng hp thc hin phu thut ct b thn kinh
17. Phu thut kt hp vi iu tr a m thc
Theo thng k ca mt s tc gi, khong 70% cc trng hp phu thut n thun b
tht bi thng do ti pht ti ch, ti vng hoc xut hin di cn sau m (thng c vi di cn
trc lc m). Do t c kt qu iu tr tt phi kt hp iu tr a m thc ngha l s
dng nhiu phng php iu tr b khuyt cho nhau. Trong ung th ngi ta thng kt hp
phu thut, x tr v cc phng php iu tr ton thn gm ha tr, min dch, ni tit v cc
phng php khc.
Phi hp trc m: S dng x tr n thun hoc kt hp x tr v ha tr trc m i
vi mt s loi ung th nh ung th v giai on xm ln rng ti ch, ti vng, ung th vng
u c, ung th trc trng xm ln chy mu. Sau khi tia x khi u nh li, chy mu to iu
kin thun li cho phu thut trit cn.
Phi hp sau m: iu tr x tr sau m s lm gim nguy c ti pht ti ch i vi mt
s loi ung th: ung th v, sarcome phn mm, ung th u c v ung th trc trng.
Phi hp phu thut v x tr sau m cn cho php iu tr bo tn ung th v khi khi
u cn nh (ct rng khi u + vt hch nch + x tr vo v v h thng hch v trong, hch
thng n. Trong sarcome phn mm c th ct u rng ri km x tr bo tn chi.

15
IV. KT LUN
Vi nhng tin b nhanh chng trong lnh vc phu thut, x tr, ha tr v nhng liu
php mi nh min dch, ni tit tr liu, phu thut phi ng mt v tr c bit h tr cho
cc phng php iu tr trn. Bc s phu thut ung th phi c hun luyn v x tr v ha tr
a ra ch nh iu tr ph hp vi tng giai on bnh.
Trong nhng trng hp phu thut phc tp, bc s phu thut ung th phi can m v
bn lnh, tuy nhin cng phi bit lc no nn dng li nhng ch cho bc s x tr hoc bc
s ni khoa ung th.
CU HI KIM TRA NH GI
1. Nu cc nguyn tc ca iu tr phu thut trong ung th ?
2. K cc loi phu thut trong iu tr bnh ung th ?
TI LIU THAM KHO
I. TI LIU TING VIT
1. B Y t, Bnh vin K, 1999. Hng dn thc hnh chn on u tr ung th, trang 15-24.
2. i hc Y khoa H Ni, 2002. Bi ging ung th hc, trang 68-74.
3. Nguyn Hng Ri, Ph c Mn, Nguyn Chn Hng, 2004. i cng phu tr ung th-Ung
bu hc ni khoa, nh xut bn Y hc, trang 72-86.
II. TI LIU TING ANH
1. Daly. J.M Bertagnolli. M, Decosse. J.j, Morton. D.l. Oncology. In: Mc graw-Hill internatonal
edition. Principles of Surgery. Pp297-360.
2. Rosenberg.S.A. Principles of Cancer Management: Surgical Oncology. Principles & Practice
of Oncology, 5th edition, pages 295-306.

1
Chng X
IU TR TIA X BNH UNG TH

Mc tiu hc tp
1. Nm c nguyn l v cc nguyn tc iu tr tia x.
2. Hiu r ch nh iu tr tia x trong ung th.
3. Nm c cc tai bin trong x tr v bin php x tr.
I. I CNG
iu tr tia x c p dng iu tr ung th hn 100 nm qua vi mc u tin c
nh du l Roentgen khm ph ra tia X nm 1895, sau ngi ta bt u p dng tia X iu
tr ung th. T ,iu tr ung th bng tia phng x pht trin thnh mt chuyn khoa su
trong Y hc.
Gia nh Curie pht hin ra cht phng x Radium nm 1898 v sau Alexander
Graham Bell gi s dng n trong iu tr tia x p st bng cch cm trc tip vo khi u c
tnh di dng cc cy kim. Sau ngun phng x bng cobalt v caesium c a vo s
dng. Cui nm 1940 tia x bng my gia tc (linear accelerators) ra i v pht trin.
Thi gian u p dng iu tr tia x, ngi ta thiu cc phng php tnh ton gii
hn liu lng mt cch chnh xc. Quy nh n v chun ca phng x u tin l liu gy ra
da. Mt trong nhng yu t lm hn ch iu tr trong thi gian ny l do mc chu ng ca da
km, do ngi ta khng dm nng liu ln cao.

2
Nhng tr ngi ban u c Courtard gii quyt nm 1934 bng cch p dng tia
x phn liu ngha l chia tng liu thnh nhng liu nh hn lm nn tng trong lnh vc x tr
cho n nay.
Vi s khm ph ra my chp ct lp vi tnh ca Godfrey Hounsfield, phng php lp k
hoch iu tr mi theo khng gian 3 chiu c thc hin v chuyn hn phng php lp
k hoch iu tr t 2 chiu sang 3 chiu. Bc s x tr v k s vt l phng x khng cn b hn
ch v liu lng bi v lp k hoch iu tr da trn chp ct lp vi tnh cho php bc s o trc
tip liu tia x cc v tr gii phu da trn hnh nh ca cc mt ct ngang.
Trong vi thp nin tr li y, k vng ca nhng k thut hnh nh mi nh cng hng
t trong nhng nm 1970 v PET (positron emission tomography) trong nhng nm 1980 cng
nh s pht trin nhng my x tr c nng lng cao, cc quang t v m in t c nng lng
cao cng vi k thut s ha chuyn iu tr tia x t khng gian 3 chiu thnh IMRT
(Intensity Modulated Radiation Therapy) thnh 4 chiu trong mt tng lai gn. Nhng tin b
trong x tr em li kt qu iu tr tt hn v t bin chng hn. Hin nay 70% bnh nhn ung
th c iu tr tia x nh mt phn trong liu trnh iu tr ung th.
II. CC LOI BC X ION HA
Trong nhng nm u ca th k 20 ngi ta pht hin ra rng mt vi cht c trong t
nhin b bin i t pht v cu trc ca chng lm cho chng tr nn bn hn. Cc cht nh
th c gi l cc cht phng x v s phn r phng x c nh ngha l s bin i xy ra
trong cc nhn ca nguyn t lm cho chng bn hn.
Cc qu trnh phn r phng x dn n s pht x ca cc ht tch in v cc tia. Hu
ht s pht x l pht ra cc ht alpha, ht beta v tia gamma. Cc pht x khc c th pht ra
positron, tiaX, v rt him trng hp pht ra ntron.

3
Cc ht v cc tia c pht ra t s phn r phng x c nng lng bt cc in
t t nguyn t mi trng vt cht m chng i qua. Cc ht, cc tia ny c xp loi l bc x
ion ha. Nh vy bc x ion ha c nh ngha l mt ht hoc mt tia bt k c nng
lng bt cc in t khi cc nguyn t, phn t. Cc bc x ion ha bt k t ngun no khi
tc ng n c th con ngi gy ra cc hiu ng sinh hc bc x lm tn thng cc t bo ca
c th ngi.
1. Cc i lng v n v o
Nng lng ca bc x ion ha c o bng n v electronvolts(eV), l n v rt nh
ca nng lng. Mt electronvolt l nng lng thu c bi mt in t khi gia tc qua hiu
in th mt volt v mt cch ton hc bng 1,6x10-19 joules. Trong thc t, n v ca nng
lng bc x ion ha thng c biu din di dng bi s ca electronvolt nh
kiloelectronvolt (keV hoc 103 eV) hoc megaelectronvolt (MeV hoc 106 eV).
2. Cc loi bc x ion ha
Cc pht x ph bin nht sinh ra t phn r phng x l cc ht alpha, cc ht beta v cc
tia gamma. Cc pht x khc c th bao gm cc ht positron, tia X v rt him l cc ht
neutron.
+ Ht Alpha: Ht alpha bao gm 2 proton v 2 neutron lin kt cht ch vi nhau.
N c th c coi l ht nhn ca nguyn t Heli c s khi nguyn t l 4u v in tch l +2e.
Ht alpha c biu din bng k hiu .
+ Ht Beta: ht Beta v c bn l ht in t m n c phng ra t cc ht nhn
phng x trong qu trnh phn r phng x. Chng c to ra khi 1 ntron trong ht nhn
chuyn thnh mt proton v 1 in t. Proton b gi li trong ht nhn cn in t th c pht
ra nh mt ht Beta. Ging nh cc in t, cc ht beta c khi lng nh (xp x 1/1840 u, u l

4
n v khi lng nguyn t) v mt in tch m n l (tc l mt in tch bng-1e). Chng
c k hin l .
+ Tia gamma: tia gamma l bc x in t c to ra t ht nhn ca mt nguyn
t. Bc x in t gm cc b nng lng cn gi l cc photon chng c truyn di dng
sng vi tc nh sng. Tia gamma khng c khi lng v in tch, n c k hiu l .
+ Positron:Positron c to ra khi mt proton c bin i thnh 1 ntron v
mt in t dng( Positron). Ntron li trong ht nhn cn positron c pht ra vi tc
ln. Positron cng ging nh ht beta nhng khc bit chnh l positron c mt in tch dng.
V th cc positron c k hiu l + ch ra s ging nhau v s khc nhau ca chng i vi
cc ht beta.
+ Tia X : Ging nh tia gamma, tia X cng l tia bc x in t khng c khi
lng v in tch. Tuy nhin tia X khc tia gamma ch tia gamma c to ra bi s bin i
trong ht nhn ca mt nguyn t trong khi tia X c to ra khi in t nguyn t b thay i
v qu o.
+ Ntron (c k hiu l n) l ht c tm thy trong ht nhn ca mt nguyn
t vi s khi l 1u v khng c in tch.
III. C S SINH HC CA IU TR TIA X
C ch chnh xc ca s cht t bo do tia x l mt lnh vc ang c tch cc nghin
cu. Hin nay ngi ta tm ra mt s c ch sau:
Di tc dng ca bc x ion ho, trong t chc sng tri qua 2 giai on bin i: giai
on ho l v giai on sinh hc.

5
1. Giai on ha l
Giai on ho l thng rt ngn, ch xy ra trong khong thi gian 10-16- 10-13 giy.
Trong giai on ny cc phn t sinh hc cu to t chc sng chu tc dng trc tip hoc gin
tip ca bc x ion ho.
Di tc dng trc tip: bc x ion ho trc tip tc ng vo DNA trong nhn t bo lm
DNA b t, gy lin kt lm cho t bo khng nhn ln c v cht.
Hnh 1: C ch sinh hc ca x tr
Di tc dng gin tip: bc x ion ho tc dng ln phn t nc (chim 75% trong c
th ngi) gy hin tng ion ho cc phn t nc to thnh cc ion H+ v OH-, cc hp cht
c kh nng oxy ho cao HO2, H2O2, chng tc dng gin tip ln DNA gy tn thng chng.
Cc tn thng giai on ny ch yu l tn thng ho sinh.
Tia phng x cng tc ng ln chu trnh t bo lm cho t bo tr nn gi yu v cht
theo lp trnh. Nhiu qu trnh hin nay bt u c lm sng t v vn dng lm cho iu tr
tia x ngy cng hiu qu hn.

6
2. Giai on sinh hc
Giai on ny c th ko di vi giy n vi chc nm sau khi b chiu x. Nhng tn
thng sinh ho giai on u nu khng c hi phc s dn n nhng ri lon v chuyn
ho, tip n l nhng tn thng v hnh thi v chc nng ca t bo. Kt qu cui cng l
nhng hiu ng sinh hc trn c th sng c biu hin ht sc a dng.
Cc yu t nh hng n sinh hc bc x
3. Liu chiu
Liu chiu l yu t quan trng nht quyt nh tnh cht v tn thng sau chiu x
Liu cng ln tn thng cng nng v xut hin cng sm.
Bng 1: Liu chiu
Liu Hiu ng
0,1Gy Khng c du hiu tn thng trn lm sng. Tng sai lc nhim sc th c
th pht hin c.
1Gy Xut hin bnh phng x trong s 5-7% c th sau chiu x.
2-3Gy Rng lng, tc, c thu tinh th, gim bch cu, xut hin ban trn da. T
vong 10-30% s c th sau chiu x.
3-5Gy Gim bch cu nghim trng, ban xut huyt, xut huyt, nhim khun,
rng long tc. T vong 50% s c th sau chiu x.
6Gy V sinh vnh vin c nam ln n. T vong 50% s c th sau chiu x k c
khi c iu tr tt nht.
7
4. Sut liu chiu
Cng vi mt liu hp th nh nhau, thi gian chiu ko di s lm gim hiu ng sinh hc
ca bc x. Nguyn nhn c gii thch bi kh nng t hi phc ca c th cc mc liu
khc nhau. Vi sut liu nh tc pht trin tn thng cn bng vi mc hi phc ca c
th. Tng sut liu th qu trnh hi phc gim nn mc tn thng tng ln,hiu ng sinh hc
s tng ln.
5. Din tch b chiu
Mc tn thng sau chiu x ph thuc rt nhiu vo din tch b chiu, chiu mt phn
(chiu cc b) hay chiu ton c th. Liu t vong khi chiu x ton thn thng thp hn nhiu
so vi chiu cc b.
6. Cc tn thng do phng x
6.1.Tn thng mc phn t
Khi chiu x, nng lng ca chm tia truyn trc tip hoc gin tip cho cc phn t sinh
hc c th ph v mi lin kt ho hc hoc phn ly cc phn t sinh hc. Tuy nhin bc x ion
ho kh lm t ht mi lin kt ho hc m thng ch lm mt thuc tnh sinh hc ca cc
phn t sinh hc.
6.2.Tn thng mc t bo
Khi b chiu x, cc c tnh ca t bo c th thay i c trong nhn v nguyn sinh cht.
Nu b chiu x liu cao t bo c th b ph hu hon ton.
Cc t bo khc nhau c nhy cm vi tia phng x khc nhau: Cc t bo non ang
trng thnh (t bo phi), t bo sinh sn nhanh, d phn chia (t bo c quan to mu, nim
mc rut, tinh hon, bung trng) thng c nhy cm phng x cao. Cc t bo thn kinh, t
bo lymph tuy thuc loi khng phn chia nhng cng nhy cm vi tia phng x. Do vy
8
khng ch nh chiu x i vi ph n c thai, ang cho con b v c bit i vi tr em nu
khng bt buc.
6.3.Tn thng mc ton c th
Tn thng sm xut hin khi b chiu mc liu cao trong thi gian ngn (chiu ton thn
trn mc liu 500mSv).
IV. N V O BC X
V o bc x ion ho cng nh o lng bc x ni chung, hin nay tn ti hai h thng
n v: n v mi l n v h thng quc t cn gi l n v chun SI, n v c l n v c
bit. Nm 1974 U ban quc t v cc n v bc x (International Commission on Radiation
Units vit tt l ICRU ) ngh vic s dng h thng quc t.
Trong o bc x tiu chun theo h thng quc t hin nay (SI), liu hp th bc x c
n v o l Joule trn kg, k hiu l J/kg.1 Joule trn kilgam (1 J/kg) l liu hp th bc x m
khi lng 1 kg ca cht b chiu x hp th c nng lng bng 1 Joule ca bc x ion ho
loi bt k. n v 1 J/kg c gi l 1 Gray (k hiu l Gy ); nh vy 1 Gy = 1 J/kg.
Bn cnh n v o chnh thng l Gray, ngy nay n v o ngoi h l Rad vn cn
c s dng rt rng ri trong lnh vc o liu hp th bc x.
1 Gy = 1 J/Kg = 100 Rad.
V. MC CH CA IU TR TIA X
1. iu tr tia x trit cn
Mc ch: Mc ch ca iu tr tia x trit cn l tiu dit hon ton cc t bo ung th
trong th tch c chiu x t c iu tr tn gc ca bnh ung th.
iu kin cn thit: Khng c di cn xa

9
Thi gian iu tr thng ko di nhiu tun bi v cn phi s dng liu dung np cao
trong khi phi bo v m lnh v nhm ti mc tiu khi u mt cch chnh xc.
iu tr trit cn, liu x tr cn thit kim sot khi u phi thp hn liu chu ng
ca cc c quan ln cn. Ranh gii gia thnh cng v tht bi l tng i hp, do bt but
phi thc hin k thut ht sc cht ch: phi cn nhc k gia nguy c ti pht ti ch v nguy
c hoi t nu chng ta tng hoc gim liu.
Ni chung, khi u pht trin nhanh nhy cm vi tia x hn l cc khi u xm ln.
Theo Pr.Jean-Pierre Gerard mc nhy cm ca nhiu loi khi u vi tia x nh sau:
Bng 1: Mc nhy cm ca khi u vi tia x
Loi Ung th Liu trung bnh tiu dit khi u
Leukeamia 15-25 Gy
Seminoma 25-35 Gy
Dysgerminoma 25-35 Gy
U Wilms 25-40 Gy
Bnh Hodgkin 35-45 Gy
U lympho khng Hodgkin 35-55 Gy
Malpighian carcinoma 55-75 Gy
Adenocarcinoma 55-80 Gy
Urothelial carcinoma 60-75 Gy
Sarcoma 60-90 Gy
Glioblastoma 60-80 Gy
Melanoma 70-85 Gy
10
2. iu tr tia x tm thi
Mc ch: lm gim s tin trin ca khi u xm ln rng ti ch hoc khi u cho di
cn khng th iu tr trit cn. iu tr nn rt ngn thi gian v liu tng i thp hn liu
iu tr trit cn.
3. iu tr triu chng
Mc ch: lm gim mt s triu chng chnh ca ung th giai on cui nh:
+ au: do di cn xng. Hiu qu gim au nhanh sau vi ln iu tr. Ngi ta
nhn thy rng 75% bnh nhn gim au mt phn hoc hon ton vo cui t iu tr.
+ Hi chng xut huyt.
+ Chn p: nh l chn p tu sng hoc r thn kinh. Chn p tu sng l mt
trong nhng cp cu ca iu tr tia x, iu tr cng sm cng tt ngay khi ngay khi xut hin
triu chng u tin. iu tr tng i c hiu qu nu bnh nhn cn cm gic 2 chi di
VI. K THUT THC HNH X TR
iu tr tia x phi m bo nguyn tc liu ti khi u v che chn tt nht t chc lnh
chung quanh. Thc hnh x tr lin quan n nhiu bc quan trng.
Ch nh iu tr tia x
Ch nh iu tr tia x c thc hin trong bui hi chn vi nhiu thy thuc ca nhiu
chuyn khoa khc nhau: Bc s x tr, bc s phu thut, bc s ni khoa ung th, bc s gii phu
bnh v bc s chn on hnh nh sau khi trnh by r rng v khi u v tnh trng ton thn
ca bnh nhn.
Mt vi bin php d phng trc khi x tr nn a ra tho lun tu theo tnh trng bnh
nhn:
11
- Chm sc v rng ming i vi cc ung th vng u mt c.
- Chm sc v dinh dng khi cn thit.
- S dng Corticoid tr liu trc khi tia x vo no.
- Lm cc xt nghim v mu, c bit l khi tia x vo mt th tch ln hoc tia
x sau iu tr ho cht.
- Lm cc xt nghim v Xquang c bit l CT-Scanner v cng hng t xc
nh mt cch chnh xc th tch bia cn iu tr.
- i vi nhng bnh nhn b kch thch, au n phi dng thuc an thn, gim
au bnh nhn nm yn trong qu trnh iu tr.
- Vi nhng bnh nhn phu thut trc phi kim tra vt thng lin so
trc khi tin hnh iu tr tia x.
- Xc nh th tch bia
Xc nh th tch bia cn iu tr ph thuc vo cc yu t sau:
- Kch thc ca khi u (cn thm s phn tch ca cc bc s Xquang)
- Bn cht t nhin ca bnh ung th (v d: tia x mt cch h thng vo hch
thng n i vi cc ung th thc qun 1/3 trn).
- Bn tng trnh bin bn phu thut, bo co v xt nghim gii phu bnh hc
(ct b c hon ton khi u hay khng, xm ln v ca nhng hch ly ra lm xt nghim hay
cha.v.v.)
Tiu chun ca IRCU
Theo tiu chun ca IRCU (International Commission on Radiation Units and
Measurements) ngui ta xc nh nhiu th tch iu tr tia x:

12
- Th tch bia th: GTV (gross target volume) lin quan n th tch r rng ca
khi u
- Th tch bia lm sng: CTV (clinical target volume) lin quan ti s xm ln ti
cc t chc chung quanh.
- Th tch bia lp trnh: PTV(planning target volume) lin quan ti bnh nhn, s
di chuyn ca khi u v s khng hon ho ca chm tia.
Lu rng cc m lnh nhy cm c th bao gm trong th tch bia lp trnh v to thnh
nhng nguy c chnh trong iu tr
S phn nh chnh xc ranh gii cn c chiu x, xem xt cc c quan c nguy c b
thng tn v liu lng chiu x l trch nhim ca bc s x tr v c s h tr ca k s vt l
phng x.
Di y l v d mt lp trnh iu tr ca ung th tin lit tuyn. Trc trng l mt trong
nhng c quan b nguy c chnh.

13
S ny c 4 trng chiu, trc trng tip nhn khong 85% liu chiu x (60-65Gy) v
chm xng i tip nhn 50% liu chiu.
VII. LIU IU TR
Liu lng s dng trong iu tr tia x c o bng Gray (Gy). Theo qui c liu iu
tr thay i ty theo loi ung th v giai on ung th. i vi nhng trng hp iu tr ng th
trit cn, c bit liu iu tr cc loi ung th biu m c thay i t 60 - 80 Gy.
Liu iu tr b tr thng trong khong 45Gy- 60Gy vi phn liu 1,8-2Gy (i vi ung
th v, ung th u mt c). Cc nh x tr ung th c th chn liu iu tr da vo mt s yu
t khc nh l bnh nhn ang iu tr ha tr kt hp, iu tr x tr tin phu hoc hu phu v
cn da vo mc thnh cng ca phu thut.
1. Phn liu iu tr
Tng liu iu tr c phn liu (tri di trong qu trnh iu tr) cho cc t bo bnh
thng c thi gian phc hi. Cch thc phn liu c th ha gia cc trung tm iu tr x tr
v ngay c theo c nhn cc bc s x tr.
Hoa k, c, Chu u s phn liu sp xp i vi ngi ln l 1,8 - 2 Gy mi ngy, 5
ngy mi tun. Anh, phn liu thng thng l 2,67 - 2,75Gy mi ngy. i vi tr em phn
liu l 1,5 - 1,7Gy mi ngy.
Trong mt s trng hp, 2 phn liu mi ngy c s dng cui ca liu trnh iu
tr. Mt trong cc ch phn liu khc c bit l CHART (Continuous Hyperfactionated
Accelerated Radiotherapy ). CHART c dng iu tr ung th phi, bao gm 3 phn liu
nh mi ngy. Mc du c nhng thnh cng ng k, CHART c th l mt cng vic cng
thng cc khoa x tr.

14
2. Theo di iu tr
S gim st iu tr lin quan n iu kin k thut ca tia x, s dung np v hiu qu
thng do cc k s vt l m nhim.
Cc iu kin gim st k thut ca iu tr tia x:
+ K s vt l v k s in lm vic trong khoa x tr gim st cc thng s k
thut v h thng in ca my x tr.
+ H thng vi tnh kt ni vi my x tr kim tra thi gian iu tr v liu lng
ca mi trng chiu.
+ Bc s x tr kim tra t th chnh xc ca bnh nhn v chm tia phng x cc
bui iu tr u tin bng cch dng h thng n chiu laser(gammagraphies).
+ Trong cc bui iu tr tip theo k thut vin tip tc thc hin iu tr theo k
hoch
3. Theo di lm sng
Theo di bnh nhn trong sut qu trnh iu tr tia x l cng vic ca bc s tia x. Khi
bt u khm v iu tr ln u bc s tia x phi gii thch cho bnh nhn phng thc iu tr
v cc tc dng ph c th gp. Lo lng,bt an v trm cm nn c xem xt v iu tr, nhng
trng hp th trng km phi cho nhp vin theo di v nn c ch v sinh, dinh dng
hp l. Nn theo di u ng trng lng ca bnh nhn. Theo di chnh xc kch thc ca
khi u nh gi hiu qu ca iu tr.
Nn c k hoch hi chn bnh nhn hng tun nh gi li p ng ca bnh nhn vi
iu tr (trng lng, th trng chung, cc c tnh v h to mu trong x tr), cc phn ng ti
ch. Bc s x tr cng phi nh gi v p ng ca khi u cng nh cc yu t tm l lo lng
ca bnh nhn.
15
Ngng iu tr tia x trong trng hp bnh nhn khng chu ng c.
Sau khi hon tt iu tr tia x, phi lm bn tng trnh chi tit v liu iu tr, k thut
iu tr s dng v p ng ca bnh nhn, bn tng trnh c gi n cc thy thuc iu
tr c lin quan v theo di.
VIII. IU TR KT HP
iu tr tia x c th kt hp vi phu thut, ho cht hoc iu tr ni tit.
iu tr tia x n thun: Ngoi tr mt s trng hp iu tr tia x triu chng, iu tr
tia x n thun c th thc hin mt s loi ung th: ung th u c, ung th tin lit tuyn,
ung th c t cung.ung th ng hu mn hoc bnh Hodgkin.
Kt hp phu thut v x tr: thng c thc hin khi ung th ang cn giai on ti
ch v ti vng.
X tr hu phu: mc ch trnh nguy c ti pht ti ch, thc hin sau khi vt thng
lin so, thng khong 1 thng sau phu thut. V d x tr vo v sau m ct 1/4 v, x tr vo
vng c sau m ung th u c.
X tr tin phu: mc ch ca x tr tin phu l gim th tch ca khi u, bin khi u
khng ct c tr thnh khi u ct b c. Khong chng 2 thng sau x tr, t chc x sau x
tr gim nhiu thun li hn cho phu thut. V d nh x tr tin phu trong ung th trc trng,c
t cung.
Kt hp x tr v ho tr: nhn chung ho tr c ch nh khi khi u c kh nng cho di
cn cao. Ho tr cn c ch nh lm gim th tch khi u i vi nhng khi u nhy cm
vi ho tr trc khi phu thut hoc tia x.
Kt hp ho tr v x tr cng lm gia tng c tnh ca c 2 phng php iu tr: c
tnh trn h to mu, c tnh trn tim mch, c tnh trn phi.
16
Nhng phc iu tr mi c thc hin ci thin ti pht ti ch v trnh phu
thut ct b rng ri:
- Kt hp ho tr v x tr trong ung th thc qun.
- Kt hp x tr ngoi, x tr p st v ho tr i vi ung th c t cung giai on
mun trnh ct b rng ri vng chu.
- Kt hp x tr v ho tr trong ung th bng quang trnh ct bng quang.
- Kt hp x tr v ho tr trong ung th thanh qun sm bo tn ging ni.
X tr ton thn: X tr ton thn c ch nh chng thi loi mnh ghp trong ghp
tu xng i vi nhng bnh nhn iu tr ho cht liu cao trong bnh bch cu cp. Bnh
nhn nhn 1 liu 8Gy (liu gy cht ngi nu bnh nhn khng c ghp tu kp thi). Liu tia
x ny cho php ph hu cc t bo tu gy thi loi mnh ghp.
IX. X TR P ST
Nguyn tc c bn: x tr p st l s dng ngun phng x t trong khi u pht x.
Nh vy khi u s nhn liu tia x cao nht v liu s gim nhanh ra t chc lnh chung quanh.
Ngun phng x s dng l cc ngun mm c th un nn c nh Iridium 192 hoc
Cesium 137 v k thut np ngun sau c c pht trin mt cch nhanh chng trong x
tr p st. Trc ht cc catheter rng c t vo bn trong khi u vi gy t ti ch hoc gy
m ton thn. V tr chnh xc ca catheter v s phn b v liu lng c kim tra cht ch,
sau tin hnh t ngun phng x vo trong catheter.
u im chnh ca x tr p st l kh nng a liu phng x ln cao trong mt th tch
rt nh v liu gim nhanh ra ngoi vi khng nh hng n t chc lnh chung quanh. iu ny
i hi cc bc s x tr c kinh nghim t mt cch chnh xc catheter vo khi u v tnh
ton chnh xc s phn b v liu lng.

17
Hnh: Dng c iu tr x trong
Cc phng php iu tr tia x p st
X tr p st xut liu thp: y l phng php iu tr x tr p st chun vi thi gian x
tr t 1 n 5 ngy vi sut liu thp (30-100cGy/gi). Liu im tip xc ca ngun l cao
nht nhng gim i mt cch nhanh chng (trong khong vi mm), nh vy cho php bo v cc
t chc lnh chung quanh.
Bnh nhn c gi li nm vi ngy trong phng tng c chn ch, c h thng che
chn bo v nhn vin y t trong qu trnh chm sc.
X tr p st sut liu cao: k thut ny s dng ngun gia tng hot phng x, nh vy
s gim thi gian tia x v gim thi gian bt ng bnh nhn.
Hnh: iu tr x p st ( Ung th c t cung )

18
Kt hp vi cc phng php iu tr khc: x tr p st ch l mt phn trong qu trnh
iu tr ung th. Thng thng x tr p st kt hp vi iu tr phu thut (i vi phn ln cc
ung th ph khoa), kt hp vi iu tr tia x ngoi (trong ung th ph khoa hoc ung th tin lit
tuyn) v mi y x tr p st cn kt hp vi ho tr.
X.IU TR BNG NG V PHNG X (Radioisotope Therapy)
iu tr tia x c th thc hin qua ng tim truyn hoc bng ng ung. V d nh
chuyn Metaiodobenzynguanidine (MIBG) iu tr neuroblastoma, hoc ung
Iode-131 iu tr ung th tuyn gip.
Nm 2002, c quan FDA ca Hoa k cho php s dng Ibritumomabtiuxetan (zevalin),
l mt khng th n dng khng CD20 kt hp vi phn t Yttrium-90. Nm 2003 FDA cho
php Tositumomab Iodine-131 (Bexxar) kt hp vi mt khng th n dng khng CD20.
Nhng thuc ny l nhng tc nhn u tin c gi l min dch phng x tr liu
(radioimmunotherapy), chng c cho php s dng iu tr bnh Non-Hodgkins lymphoma
khng p ng vi cc phng php iu tr khc
XI. CC PHN NG CA TIA X
iu tr tia x l phng php iu tr khng gy au. iu tr tia x triu chng vi liu
thp (v d iu tr tia x di cn xng ) thng rt t hoc khng gy ra triu chng g. iu tr
vi liu cao gy ra nhiu phn ng ph trong qu trnh iu tr . Phn ng xy ra trong thi gian
iu tr hoc 2-3 tun sau hon tt iu tr (phn ng ph cp tnh), trong nhiu thng hoc nhiu
nm sau iu tr (phn ng ph lu di), hoc phn ng ph xy ra sau khi iu tr tia x li (phn
ng ph tch ly). Tnh cht, mc trm trng v thi gian ko di ca phn ng ph ty thuc
vo c quan tip nhn tia x, vo phng php iu tr (loi tia x, liu lng, sut liu chiu, ha
tr ng thi ) v ph thuc vo bnh nhn.

19
Hu ht cc phn ng do tia x l c th d on c. Phn ng ph thng gii hn
nhng vng b chiu x. Mt trong nhng mc ch ca iu tr tia x hin i l lm gim phn
ng ph ti mc thp nht v gip bnh nhn hiu c v i mt vi nhng phn ng ph
khng th trnh khi .
Bnh nhn thng c c phn ng cp v mn tnh, tuy nhin thy thuc quan tm nhiu
hn n phn ng mn tnh bi v phn ng cp tnh gy ra kh chu cho ngi bnh nhng c
th iu tr khi hon ton, phn ng mn tnh gy tn thng t chc kh hi phc, ko di mn
tnh v tin trin nng thm.
C 2 gi thuyt c a ra gii thch cho cc thng tn mn tnh. Mt l thuyt cho
rng thng tn mn tnh gy ra do s ph hu cc vi mch mu trong qu trnh iu tr tia x,
trong khi gi thuyt khc cho rng thng tn mn tnh do s suy yu ca t bo mm sau x tr.
1. Phn ng cp tnh
Thng tn t bo biu m b mt (epithelial surfaces): cc t bo biu m b mt nh da,
khoang ming, vng hu hng, nim mc rut, nim mc ng tit niu. Mc thng tn ty
thuc vo s hi phc ca t bo biu m.
1.1.Da
Bt u tr nn mu hng v au sau vi tun iu tr v ko di sau khi kt thc iu tr
khong 1 tun v da c th b nt nhng thng hi phc nhanh chng. Phn ng da c khuynh
hng tr nn trm trng nhng vng c np gp ca da nh np gp di v ph n, sau
tai v cc im t.
1.2.Cc biu m lt
Nim mc khoang ming, hu hng, thc qun v rut c th b thng tn do tia x. Nu
tia x vo vng u c, au v vim lot vng khoang ming, hu hng thng xy ra. Nu trm
20
trng bnh nhn nut au, n ung km dn n suy kit. Mt mi v xy ra sm trong tun th 2
iu tr km theo kh ming.
- Phn thp ca rut gi c th b nh hng trc tip bi tia x do iu tr trc
tip vo vng hu mn trc trng, hoc b nhim x do iu tr tia x vo vng khung chu nh
tin lit tuyn, bng quang, c t cung .v.v. Triu chng c bit l au, bng chng, tiu chy
v nn ma.
1.3.Mu v c quan to mu
Biu hin lm sng l cc triu chng xut huyt, ph n,thiu mu. Gim lympho, bch
cu ht,tiu cu v hng cu. Xt nghim tu xng thy gim c 3 dng sm nht l dng hng
cu.
1.4.Sng ph
Sng n cc m mm c th gy ra nhiu triu chng trong qu trnh iu tr. Ph no l
bin chng thng xy ra trong khi iu tr tia x vo khi u no, hoc cc khi u di cn ln no,
c bit vi nhng trng hp c tng p lc s no trc . i vi cc khi u gy cht
hp gn hon ton khu knh (v d thc qun,h hng thanh qun, kh qun, ng mt, trc
trng), tia x c th gy ph n v tc nghn hon ton. C th phng bng cch phu thut
trc khi iu tr tia x hoc dng steroids trong qu trnh iu tr tia x chng ph n.
1.5.V sinh
Bung trng v tinh hon rt nhy cm vi tia x, chng khng th to ra c giao t sau
khi hp th cc liu iu tr tia x thng thng, do cn che chn tt khi iu tr tia x vo
vng chu.
1.6.Mt mi ton thn

21
2. Phn ng mun
Cc phn ng mun lin quan n v tr, liu iu tr, th tch chiu x v thi gian chiu
x. Cc phng php iu tr khc nh l phu thut, ho cht lm trm trng thm bnh lin
quan n x tr
2.1. X ha
M b chiu x c xu hng tr nn t n hi thng do qu trnh so ha lan ta.Tia x
liu cao vo vng mt c gy x ho lm hn ch vn ng, gy kht hm n ung kh khn.
2.2. Rng tc
Rng tc thng xy ra nhng bnh nhn x tr vo no. Khng ging nh rng tc
trong ha tr, rng tc do x tr kh phc hi v thng ch gii hn vng b chiu x.
2.3.Kh cc tuyn tit
Tuyn nc bt v tuyn l chu c liu khong 30Gy trong phn liu 2Gy mi ngy.
Trong iu tr x tr ung th u mt c thng s dng liu cao hn nhiu do thng gy tn
thng tuyn nc bt v tuyn l gy kh ming (xerostomia) v kh mt (xerophthalmia) lm
nh hng trm trng cht lng sng ca bnh nhn. Cc tuyn m hi cng ngng hot ng
gy kh da v kh vng m o khi tia x vo vng chu.
2.4. Nghn cc h thng bch huyt di da gy ph bch huyt, c th kt hp vi cc giai on
vim qung (erysipelas).
2.5 Suy nhc
Suy nhc l triu chng thng thng ca iu tr tia x v c th ko di vi thng n
vi nm . Thiu nng lng, gim cc hot ng v lun lun cm thy mt l cc triu chng
thng xuyn.
22
2.7. Ung th
Tia x c th gy ra ung th, v ung th th hai bt gp mt s t bnh nhn sau iu
tr tia x.
2.8. Phn ng ph do tch ly liu (Cumulative side effects): phn ng phdo tch ly liu khng
nn nhm ln vi phn ng mun. Phn ng ph do tch ly liu s bin mt trong thi gian ngn
cn phn ng mun c biu hin lu di. Tia x li nhng trng hp ny cn ang tranh ci.
2.9.Phn ng v sinh th
Gim tui th, c thu tinh th, tn sut xut hin bnh ung th cao hn l ung th mu,
ung th da, ung th xng, ung th phi.
2.10. Phn ng v di truyn
Tng tn sut xut hin cc t bin v di truyn, d tt bm sinh, qui thai. Hiu ng ny
cn gi l hiu ng ngu nhin do bn cht ngu nhin ca n. Hiu ng ny xy ra trong ton b
di liu
CU HI KIM TRA NH GI
1. Nm c nguyn l v cc nguyn tc iu tr tia x.
2. Hiu r ch nh iu tr tia x trong ung th.
3. Nm c cc tai bin trong x tr v bin php x tr.

23
TI LIU THAM KHO.
1. Nguyn B c, Nguyn Chn Hng, 2002. Cng tc phng chng ung th Vit Nam v vai
tr ca ghi nhn ung th trong cng tc phng chng ung th. Ti liu tp hun ghi nhn ung th
2. Phm Thy Lin, 1999Tnh hnh ung th Vit Nam, nh xut bn Nng.
3. Oxford Handbook of Oncology 2002, Epidermiology of cancer, pages 3-11.

1
Chng XI
HA TR UNG TH
Mc tiu hc tp
1. K c mc p ng vi ha tr ca mt s loi ung th.
2. Nu c c ch ca ha tr ung th.
3. K c cc c tnh ca ha tr ung th.
I. I CNG
Ha tr ung th l mt trong cc bin php iu tr ung th mang tnh cht ton thn.
Bn cnh cc phng php iu tr ti ch-ti vng nh phu thut v x tr, cc bin php
iu tr ton thn ngy cng c nhng ng gp quan trng trong iu tr v chm sc bnh
nhn ung th.
Ha tr ung th thng c hiu nh l phng php iu tr ung th bng cc thuc
ha hc gy c t bo (cytotoxic drugs) phn bit vi iu tr ni tit (hormonotherapy)
dng cc tc nhn ni tit v iu tr sinh hc (biologic therapy) dng cc tc nhn lm bin
i p ng sinh hc (biologic modulators). Thc ra s phn nh trn ch c tnh cht tng
i v hiu qu ca tt c cc bin php iu tr ton thn trn u thng qua c ch tc ng
cui cng l lm thay i p ng sinh hc ca c th theo hng chng ung th. Hn na, tt
c cc tc nhn iu tr ton thn (thuc gy c t bo, ni tit hay min dch, sinh hc)
u c bn cht ha hc. Do vy ngi ta thng pht trin khi nim ha tr ung th nh l
bin php iu tr ton thn bng cc thuc ha hc, cu thnh mt ni dung rt quan trng
ca ung th hc ni khoa.
II. VAI TR CA HA TR I VI CC LOI UNG TH
Vai tr ca ha tr khc nhau theo tng loi ung th v theo tng tnh hung lm sng
c th. Tuy vy ngi ta thng chia thnh cc nhm theo mc p ng vi ho tr:

2
Nhm ung th c th iu tr khi bng ho tr
+Bnh bch cu lymph cp tr em
+U lymph Burkitt
+Ung th nhau thai
+Ung th t bo mm tinh hon
+Bnh Hodgkin v mt s u lymph c khng Hodgkin c m hc thp
hoc trung gian
+ U Wilms
+ Ung th t bo mm tinh hon
Nhm ung th ho cht c kh nng ko di thi gian sng thm cho ngi bnh
+ Ung th biu m tuyn v
+ Bnh bch cu lymph mn
+ Mt s u lymph c tnh khng Hodgkin
+ Ung th biu m bung trng
+ Ung th phi t bo nh
+ U qui tinh hon
+ Ung th vng u mt c
+ Bnh bch cu tu cp
Cc loi ung th ha tr c vai tr ci thin thi gian sng thm
+ Sarcom xng
+ a u tu
+ Ung th phn mm
+ Ung th d dy
3
+ Ung th bng quang
+ Ung th tin lit tuyn
+ Ung th phi khng phi t bo nh
+ Ung th phi t bo nh
Cc loi ung th t nhy cm vi ha cht
+ Ung th i trc trng
+ Melanome c
+ Ung th ty
+ Ung th thn
III. C CH CA HA TR UNG TH
hiu r c ch ca iu tr ha cht chng ung th, chng ta cn nm mt s khi
nim v s pht trin ca t bo v tc ng ca thuc ln cc t bo ca khi u sau y:
1. Chu k t bo
Tng hp DNA khng din ra lin tc m gin on t pha phn bo (mitosis) n k
phn bo khc. Thi gian gia 2 ln phn bo c chia thnh mt s giai on.
Bao gm 4 giai on hay 4 pha.
Pha G1: Thi gian t lc kt thc phn bo n khi bt u pha S. Giai on
ny t bo tp trung chun b tng hp RNA v cc protein chc nng c lin quan.
Pha S: giai on tng hp DNA
Pha G2: khong thi gian ngn nhn t bo chun b cho s phn bo.
Pha M: giai on phn chia t bo
Pha G0 gm cc t bo khng tham gia chu k t bo. y l cc t bo khng
p ng vi cc tn hiu khi xng vic tng hp DNA m cc t bo pha G1 vn c. Tuy

4
vy cc t bo pha G0 vn tng hp RNA v cc protein chc nng, vn duy tr chc nng
ca t bo bit ha. Cc t bo pha G0 cn l ngun d tr v sn sng i vo chu k t bo,
tham gia phn chia ti lp, gia tng dn s ca khi ung th.
Hnh 1. Cc giai on phn bo-s khng ng b dn s t bo
2. ng hc ca t bo
Khi u thng khng thun nht m c to bi hn hp t bo ti cc giai on
khc nhau. C ba nhm c m t:
Cc t bo tham gia vo cc giai on phn chia tc l nhm t bo ang trong chu k
t bo.
Cc t bo c kh nng tham gia vo cc giai on phn chia nhng cha tham gia
phn chia gi l cc t bo pha G0.
Cc t bo c loi ra sau mi chu k t bo v khng th quay tr li chu k t bo
gi l cc t bo cht t nhin.
S lng t bo thuc mt trong ba nhm trn thay i tu tng khi u, tng loi bnh
ung th v tng c th ngi bnh.

5
3. Thi gian nhn i
Thi gian nhn i ca ung th l thi gian cn cho mt khi u tng gp i s lng
t bo. Nghin cu invitro cho thy thi gian ny dao ng t 15 gi cho n 72 gi.
U Thi gian nhn i (ngy)
U lymph Burkitt 1.0
Ung th nhau thai 1.5
Bnh bch cu cp th lymph 3-4
Hodgkin 3-4
U qui tinh hon 5-6
Ung th v 60
Ung th i trng 80
Ung th phi khng phi t bo nh 100
4. Khi u ln
Lm hn ch kt qu ho tr bi v:
- Mt s lng ln t bo thi k G0
- H mao mch nui dng u khng ng nht, mt s vng thiu mu nui
dng hoc hoi t nn thuc ho cht kh vo.
- Mt s lng t bo i hi phi iu tr nhiu t, hnh thnh s khng
thuc.
Chnh v cc nguyn nhn trn, nn trong mt s trng hp nh ung th bung trng
ngi ta tin hnh phu thut cng ph khi u (debulking surgery) lm tng nhy cm ca
u cn li vi ho tr.
6
5. Thi gian iu tr
Hnh 2: Mi lin quan gia s t bo khi ung th v cc t ha tr
Da vo s trn chng ta nhn thy mi mt chu k ha tr s tiu dit s l ng
khng i tng s t bo ung th ch khng tiu dit mt s lng tuyt i t bo. Chnh v
vy ha tr phi c thc hin qua nhiu t gim dn dn s t bo ung th. Kh nng
tiu dit ton b t bo ung th bng ha tr l mt iu rt kh thc hin v bn cnh s tch
t c tnh khi ha lu di cn c hin tng khng thuc ca t bo bu. Tnh trng bnh n
nh lu di trong nhiu trng hp l do vai tr min dch chng ung th ca c th ngi
bnh.
6. S khng thuc
C ch nh sau:
+ Dng thuc khng liu
+ Gim hot tnh ca tng loi thuc
+ Gim s cung cp cc cht chuyn ha.
+ Vy gim thiu s khng thuc cn chon la thuc da theo nguyn tc
sau:
7
+ Ch s dng thuc khi bit c tc dng vi loi t bo
+ Dng cc loi thuc c cc c ch khc nhau ln cc giai on khc nhau ca
s phn chia t bo
+ Liu lng thuc khng ging nhau
+ C tc dng hip ng chng ung th
III. PHN NHM THUC CHNG UNG TH
1. Nhm chng chuyn ho
Tc ng vo qu trnh chuyn ho cc cht pyrimidine v purine. V d 1. 5 Fluoro-
Uracile (5FU) c ch sinh tng hp vng purine, c ch methyl ho axt deoxyurydylic thnh
axit thymidylic; 2. methotrexate c ch men kh dihydrofolate reductase cn thit cho vic
to cc folate kh vn l cc gc methyl trong tng hp thymidine
- Methotrexate - Cytosine arabinos
- 6 Mercaptopurine - Gemcutabine
- 5 Fluorouracil
2. Nhm Alkyl ho, mutard nit
Cc nhm alkyl c trong cu trc phn t s gn vo cu trc i in t trong DNA to
ra cc lin kt cho gia 2 chui DNA v cc lin kt ngang gia cc baz nit gn nhau lm
c ch hot ng ca DNA.
- Chlorambucine - Cisplatine
- Mechlorethamine - Dacarbazine
- Cyclophosphamide
3. Nhm cc sn phm t nhin (cc khng sinh chng bu)
Nhm ny gy cn tr qu trnh sao chp axit ribonucleic (RNA) t lm ngng tr
tng hp protein.
8
- Adriamycine - Actinomycine D
- Daunorubicine - Mitomycine Cvv
4. Nhm cc alkaloid thc vt
Tc ng theo nhiu c ch:
- nh hng hot ng ca thoi v sc trong qu trnh phn bo (cc vinca alkaloids,
nhm taxane)
- c ch enzyme topoiomerase I v II cn thit cho vic tho xon ca DNA trong qu
trnh sao chp.
- Vincristine - Etoposide
- Vinblastine - Paclitaxel, docetaxel (nhm taxane)
5. Nhm cc thuc khc
Hot ng kiu enzyme thu phn protein (L-asparaginase, Hydrourea...)
Cn ch rng c ch tc ng ca cc ho cht chng ung th l khng c tnh c
hiu. Ho cht cng nh hng n t bo v t chc m bnh thng nn thng gy ra cc
tc dng ph.
Hin nay ngi ta v ang nghin cu tm ra cc loi thuc c tnh c hiu cao
do c c ch chn lc hn da vo s tin b ca sinh hc ung th m c th l gen sinh ung
th v c ch hot ng ca n.
6. Cc phng php ha tr ung th khc
Ha cht iu tr di cn xng : Nhm Diphosphonate : pamidronate, zoledronic
acid
iu tr min dich :
iu tr min dch th ng khng c hiu: interferon, interleukin
iu tr min dch ch ng khng c hiu : vaccine BCG bm vo bng quang.

9
Liu php iu tr nhm trng ch phn t : L phng php iu tr mi bao gm
Cc khng th n dng :
Trastuzumab (Herceptin)
Rituximab (Mabthera, Rituxan)
Alemtuzumab (Mabcampath)
Cetuximab (Erbitux)
Cc phn t nh hot tnh :
Imatinib mesylate (Gliveec)
Gefitinib (Iressa)
Erlotinib (Tarceva)
Cc cht chng tn to mch mu nui khi u :
Bevacizumab (Avastin)
Thalidomide
Cc cht chng proteasome :
Bortezomide (Velcade)
IV. CC CH NH HA TR UNG TH
Cc ch nh chnh bao gm:
Ha tr gy p ng: Ch nh cho cc ung th giai on tin xa
Ha tr h tr sau iu tr ti ch v ti vng cc ung th giai on sm
Ha tr tn h tr trc khi iu tr ti ch v ti vng cc ung th giai on sm
Ha tr ti ch nhm lm tng nng thuc c hiu qu ti v tr tn thng bng
nhiu k thut nh bm thuc vo cc xoang hc ca c th, bm thuc vo ng mch

10
V. C TNH CA HA TR
Ha tr gy ra nhiu c tnh v c phn thnh 2 nhm chnh :
c tnh cp :
c tnh mun :
Cc thuc ha tr ung th u gy nn nhng tc dng phu bn cnh hiu qu mong
i l c ch tng trng t bo ung th. Cc t bo, t chc ca c th c tc tng trng
nhanh nh nim mc ng tiu ha, h to huyt, t bo lp y biu m, t bo sinh
dcthng c biu hin c tnh ha tr r rang nht.
c tnh ca ha tr rt a dng v c phn theo mc nng t I n IV hoc theo
h c quan. C th phn loi c tnh ha tr theo thi im xy ra nh di y:
Phn ng tc thi: sc phn v rt him xy ra. Mt vi lai thuc nh paclitaxel hoc
cc khng th n dng nh rituximabc th gy phn ng sc phn v nn cn phi iu
tr d phng trc v theo di cn thn trong khi s dng.
Cc phn ng sm: Xy ra trong vng mt vi ngy sau ha tr
Bun nn v nn ma
Mt mi, st, phn ng gi cm
Phn ng mun sau vi ngy n vi thng sau ha tr
Gim sinh tu: Gim bch cu, thiu mu, gim tiu cu
Ri lon tiu ha: au bung, chn n, tiu chy, to bn
H lng tc mng: rng tc, xam da, thay i mu sc mng
H thn kinh: D cm u chi, gim thnh lc
H sinh dc: Ri lon kinh nguyt, v kinh, v sinh
Qui thai
11
Cc phn ng mun: thng sau nhiu nm
V sinh
t bin di truyn
Sinh ung th th hai
Suy tim
X phi
Ngoi cc tc dng ph thng gp nh bun nn, nn ma, rng tc, suy tu mi
thuc ha tr c th c cc tc dng ph chuyn bit nn cn phi ch khi phi hp cc
thuc vi nhau. Thng ngi ta thng trnh phi hp cc thuc c cng c tnh v trnh
s dng cc thuc vt qu liu tch ly ti a cho php trnh cc c tnh nng khng hi
phc c.
VI. KT LUN
Ha tr l phng php iu tr ung th mang tnh cht ton thn. Nhng tin b vt
bc trong nhng thp nin va qua gp phn khng nh v nng cao vai tr ca ha tr ung
th. Cc tin b trong lnh vc sinh hc ung th v ang hon thin phng php iu tr
ny vi cc thuc mi c c ch tc ng mang tnh c hiu hn, cc phng php nng
hu hiu hn.
CU HI KIM TRA NH GI
1. K cc mc p ng vi ha tr ca mt s loi ung th ?
2. Nu c ch ca ha tr ung th ?
3. Nu cc thng gp c tnh ca ha tr ung th ?

12
TI LIU THAM KHO
1. Nguyn B c. 2003. Ha cht iu tr bnh ung th. Nh xut bn Y hc. Trang 11-56,
288-318
2. Nguyn Chn Hng. 2004. Ung bu hc ni khoa. Nh xut bn Y hc. Trang 111-146.
3. Richard R. Love.1995. Cm nang ung bu hc lm sng (Ti liu dch t Manual of

Clinical Oncology). Trang: 289-320. Nh xut bn Y hc Tp HCM.
4. David S. Fischer, M Tish Knobf, Henry J. Durivage, Nancy J. Beaulieu. 2003. The cancer
chemotherapy handbook. pp 1-15, 37-48. 479-511. Mosby press.
5. Jim Cassidy, Donald Bissett, Roy A J Spence OBE. 2002. Oxford handbook of oncology.
pp 135-180. Oxford press.
1
Chng XII
IU TR GIM AU TRONG UNG TH
Mc tiu hc tp
1. Gip sinh vin nh gi c mc au trong ung th.

2. S dng cc thuc gim au theo tiu chun quc t
I. I CNG
Bnh nhn ung th cn c gim au tt c cc giai on bnh ca h. Nhiu nghin
cu chng t rng khong 75% bnh nhn ung th giai on mun u c au mc
trung bnh hoc au d di.
Vit Nam c khong 79% bnh nhn ung th c au k t lc c chn on. Nhiu
tc gi cho rng au bnh nhn ung th khng c nh gi ng mc bi nhiu l do:
+ Thy thuc khng nh gi ng mc au ca bnh nhn.
+ Thy thuc nghi ng v cm gic au ca bnh nhn.
+ Bnh nhn khng bo s au n ca h v s lm phin thy thuc hay nu c
bo th khng c x tr g hoc i khi s s dng thuc gim au.
Tt c bnh nhn phi c iu tr khi c xut hin au lm gim s au n v ci
thin cht lng cuc sng tt c cc giai on trong qu trnh bnh tt ca h.
Thuc iu tr au gm:
+ Loi b hon ton cn au hoc t nht cng lm gim mc trm trng ca
cn
+ au ti mt mc c th chu ng c.
2
+ Phng nga cn au ti pht
+ Lm gim au bnh nhn c th thc hin c cc sinh hot hng ngy.
iu tr gim au ty thuc vo p ng ca tng c th vi nhng phng php nh:
iu tr bng thuc, gy t, phu thut thn kinh, tm l hc. Song bi ny ch yu tp trung vo
iu tr bng thuc bi v trong lnh vc ny c s hiu bit y v kinh nghim lm sng
v phng hng iu tr chung cho tt c bnh nhn ung th c au.
Cc th nghim cho thy rng thuc c hiu qu trong phn ln bnh nhn, nu n
c s dng chnh xc: ng thuc, ng liu vo ng giai on.
II. VI NT LCH S
Lch s pht trin ca iu tr triu chng bt u t th k 18
Baptiste Godinot thnh lp vin ung th u tin, nhn iu tr nhng khi u hoi t, thi
ra
Nm 1842 Jeanne Garnier, mt qu ph tr thnh lp hospice cng hin cuc i ca
h cho nhng bnh nhn khng th iu tr c.
Quan im chm sc triu chng hin i n t Cicely Saunders, b thnh lp
Christopher Hospice chm sc cho nhng bnh nhn ngho ang hp hi. B l ngi u tin s
dng Morphin iu tr au cho bnh nhn ung th giai on cui.
Elisabeth Kuble- Ross, thy thuc thy s sng Chicago, b nghin cu cc bc ca
qu trnh hp hi v ku gi mi ngi gip h.
Pro. Maurice Abiven l ngi u tin a chng trnh ging dy chm sc triu chng
vo cc trng i hc.
3
Cicely Saunders Elisabeth Kuble-Ross Pro. Maurice Abiven
III. CC NGUYN NHN GY AU
au nhng bnh ung th c th l do:
Gy nn bi chnh bn thn ung th (rt ph bin). Bn thn ung th gy au do cc c
ch :
+ Xm ln ti t chc phn mm.
+ Thm nhim ti ni tng.
+ Thm nhim ti xng.
+ Chn p thn kinh.
+ Tn thng thn kinh.
+ Tng p lc ni s.
Lin quan ti ung th: v d nh co c, sng n bch mch, to bn, vim lot do nm
lu). M b thng tn do do bi nhim, do thiu mu cc b...

4
Lin quan ti iu tr ung th: v d nh au do so mn tnh sau phu thut, vim nim
mc do iu tr bng ha cht.
Gy ra bi mt ri lon ng thi: v d nh thoi ha ct sng, vim xng khp.
Nhiu bnh nhn ung th giai on mun, au nhiu do s phi hp ng thi nhiu
nguyn nhn trn.
IV. NH GI V PHN LOI AU DO UNG TH
1. nh gi au
L mt bc quan trng c tnh cht quyt nh trong kim sot au do ung th. Phi
khm ton din, cn tm hiu thm c bnh khc cng i km vi ung th hay khng, phi nh
gi chc nng gan thn, theo di nh hng ca thuc gim au ln s hp thu, chuyn ha v bi
tit. Phim X quang v CT-Scanner v cc vng lin quan v x hnh xng cng cn thit so
snh vi cc kt qu khm trc y theo di din bin bnh v d on, tin lng bnh.
Khai thc bnh s ca cn au
Thi gian
- au bt u t khi no?
- Cn au ko di bao lu
- au xut hin thng xuyn hay au tng cn
V tr
- V tr au au, c th ch chnh xc v tr au
- au c lan i u khng?
5
Tnh cht cn au
- Bo bnh nhn m t cn au. au ging nh g: au nh kin b, nng rt, au
nh tn bn, au nh dao m.
- C gng phn bit au do cm gic v au do thn kinh
- Yu t lm du hay gy au: iu g lm du au hay au tng ln.
- Mc trm trng : au n mc no? Thng p dng thang im t 0-10.
0 : khng au v 10 l au tt bc
bnh nhn t chn im au ca mnh sau khi c hng dn. V d au
5/10 hoc 7/10 .v.v.
Thang im au:Thang im au dng nh gi mc trm trng ca triu chng
au. Thang im au gip bnh nhn m t mc trm trng cn au ca h vi thy thuc v
thang im au cn gip thy thuc trao i thng tin v kinh nghim iu tr au vi cc ng
nghip.
Tr em c th dng loi bng im c hnh nh d hiu hn.
V. PHN LOI AU DO UNG TH
1. au do cm gic
L loi au thng gp nht bt u t cc th th nhn cm gic au thn kinh ngoi
bin khi n b p, cng, ko hay b kch thch bi cc cht trung gian ha hc nh
prostaglandin phng thch t t chc vim (th d: mt ung th xm ln vo m mm, u lm
cng thy gan, ph hy xng).
au do cm gic thng chia thnh cc dng nh sau :

6
+ au nng (v d : try xc, si lot da, vim si lot da nim mc).
+ au su: au xng, khp.
+ au ni tng: bng, tng rng b kch thch do di cn, do nghn, sng hoc b
vim nhim do nhiu nguyn nhn khc nhau. au ny thng khng khu tr v c cm gic nh
b chn p.
2. au do thn kinh
au xut pht t chnh cc si thn kinh khi b kch thch bi p hay xm ln v d :
Ung th xm ln vo m ri thn kinh cnh tay.
Chn on bng cch :
+ Tm yu t bnh l c th gy tn thng hay kch thch cc trc v si thn
kinh.
+ Kim tra cc triu chng ca dy thn kinh: t tay, thay i cm gic, yu c
.v.v...
+ iu tr bng thuc gim au thng thng t p ng.
Hai dng au ny i hi iu tr vi cc loi thuc khc nhau. au do cm gic lun p
ng vi cc thuc gim au, bao gm thuc c ngun gc opioids. au thn kinh c th gim au
mt phn vi thuc v c ngun gc opioids v cn cho thm cc thuc n nh mng t bo thn
kinh v thuc c nh hng ln cht dn truyn (th d : thuc chng trm cm v thuc ng
kinh).
7
VI. KHM LM SNG
Khm lm sng mt cch t m ton c th v h thng cc c quan s gip pht hin ra
cc nguyn nhn gy au. C gng trnh gy kh chu, au n cho bnh nhn khi thm khm.
- V d nh khi t ngi dy s lm bnh nhn au n th thm khm 2 trng phi pha
sau lng bng ng nghe l khng cn thit.
- Khi cn au cn tr cc hot ng bnh thng, nn thc hin thm khm h thn kinh
mt cch h thng.
Cc xt nghim cn lm sng v chn on hnh nh
Cc xt nghim cn lm sng gip chn on c nguyn nhn gy au:
- Chp Xquang thng v chp ct lp vi tnh c th pht hin c khi u, gy
xng, chn p thn kinh hoc nhng nguyn nhn gy au khc.
- Chp x hnh xng pht hin ra au do di cn xng.
- Chp PET-Scan pht hin di cn.
- Sinh thit hoc xt nghim t bo hc c th pht hin u c tnh hoc vim.
- Xt nghim mu v xt nghim vi khun c th pht hin ra nguyn nhn nhim
trng.
- Xt nghim huyt thanh c th pht hin ra bnh thp khp, bnh t min.v.v.
8
VII. CCH DNG THUC GIM AU
1. Nguyn tc dng thuc gim au
- Theo ng ung : Dng n gin, d dng nht ngoi tr trng hp bnh nhn khng
th ung c hoc cn au qu trm trng phi cn tim hoc chuyn c tc dng gim au
nhanh.
- Theo bc thang: bc u tin l dng thuc khng c Opioide, nu au khng gim th
dng Opioide nh ri n mnh (morphin).
- Theo gi: khng ch n khi bnh nhn au mt cch chnh xc, nn cho thuc gim
au u n liu k tip c tc dng trc khi cn au xy ra.
- Theo tng c th: khng c liu chun cho nhng thuc Opioide, liu ng l liu c tc
dng gim au cho bnh nhn.
- Nguyn tc chung: ngn chn au tt hn l iu tr au.
2. Bc thang gim au
T chc Y t Th gii a ra khi nim bc thang gim au nh l mt cch khuyn khch
vic s dng thch hp cc Opioide gim au cc quc gia t s dng loi thuc ny. Bng ny
nhn mnh trong cc cn au d di cn cho thuc gim au mnh (Th d : cc loi thuc
Opioides) v khng gii hn liu ti a. Liu hp l l liu mang li hiu qu gim au m khng
c ri lon no do tc dng ph ca thuc. Thuc Opioides l mt thut ng dng ch cc
OPIATES c ngun gc t nhin nh Morphin v loi Narcotic tng hp nh Methadone.

9
BC III au tt bc Morphin, Pethidine, Oxycodone
BC II au trung bnh Codeine, Tramadol, NSAIDS
BC I au nh Paracetamol, Aspirine, NSAIDS
3. Cc thuc gim au
iu tr cn au nh (bc I theo bc thang ca WHO):
Dng cc thuc gim au khng c opioid, c th kt hp cc thuc gim au khc nu
nguyn nhn gy au do thn kinh.

10
3.1.Cc thuc Non-opioid
Thuc khng vim khng cha Steroid (NSAIDS) c nhiu loi, trong chm sc lm du
thng s dng.
+ Ibuprofen 400 mg-800 mg ngy 3 ln, liu ti a khng qu 2400mg/ngy.
+ Naproxen 250 mg-500 mg ngy 2 ln hoc ta dc 500 mg hay loi phng
thch chm 1000 mg.
+ Diclofenac 25 mg-75mg/mg ngy 2 ln, liu ti a 200mg/ngy
+ Indomethacin 25 mg-50 mg ngy 3 ln.
+Acetaminophen (paracetamol) 500-1000mg ngy 4 ln, ti a khng qu
4000mg/24 gi
y l cc thuc ph tr tt gim au km vi gim vim, c bit l au lin quan n
xng. Cc thuc Nsaids u kch thch d dy. Do nn ung sau khi n v ung km cc
thuc khng th th H2 (th d: Ranitidine 150 mg-2 ln/ngy hay trc khi ng) hoc Sucralfate
1g - 4 ln/ngy c th bo v nim mc d dy, thn trng i vi nhng ngi suy chc nng
gan thn, cc bnh l v h to mu.
iu tr cn au trung bnh ( Bc II theo thang im ca WHO)
S dng cc thuc opioid nh:
+ Efferalgan codein (zandol) phi hp vi codein (30 mg codein + 500 mg
Paracetamol)
11
+ Codein photphate vin 30 mg l 1 loi thuc phin nh, c tc dng hip ng
gim au cng vi Aspirin hay Paracetamol, dng 60 mg/4-6 gi, liu ti a 360mg/ngy, d gy
to bn nn thng xuyn dng km theo thuc nhun trng.
+ Dextro propoxyphene thng phi hp vi Paracetamol (Dextro Propoxyphene
30 mg + paractamol 400 mg) c dng cho cn au va phi, c tc dng gim au tt.
+ Tramadol: l loi opiod tng hp, c tc dng gim au thn kinh trung ng,
dng ng ung c hiu qu, Tramadol mnh gp 2 ln codein vin 50 mg, t gy bn.
iu tr cn au tt bc
S dng cc thuc pioid mnh
Trong trng hp cng cn au trm trng s dng cc thuc gim au bc I v
bc II khng hiu qu th s dng cc thuc opioid mnh (nh Morphin), c th kt hp
vi cc thuc Non-steroid hoc cc thuc gim au thn kinh nu nguyn nhn gy au do thn
kinh.
+ Morphin sulfat
Liu ung: Bt u liu 5mg, nh gi li sau 60 pht. Nu cn au vn cn
trm trng, tng liu ln hng gi n khi c hiu lc gim au, cho liu lng ny mi 4 gi/ln.
C th gia tng liu ln 50% hoc 100% nu cn au vn cn dai dng.
+ Morphin phng thch chm c kim sot (Skennan), phng thch Morphin
t t trong mt thi gian di v cho mt nng n nh vi liu lng u n. Skenan c liu
10 mg, 30 mg, 60 mg. Skenan LP 2ln/ngy ung hoc bm qua sonde d dy. Vin thuc phng
thch chm t gy nn i so vi tim v ko di thi gian lm gim au sut m. Thng cho 1
liu t 8-12 gi l an ton.

12
Trong trng hp s dng cc thuc Opioids ung cng khng c tc dng na, iu
tr cn au mt cch hiu qu phi dng Morphin tim, c th s dng tim tnh mch hoc tim
di da. Vi liu lng nh c tim Morphin di da 2-5mg, nh gi hiu qu gim au sau
khi tim 20 pht v tng dn liu n khi bnh nhn ht au. Tip theo s chuyn thnh bc iu
tr gim au c liu lng trn, tim khong cch 4 gi/1ln.
Gi s liu bt u 5 mg, liu th hai 10 mg khng gim au nhiu, nhng vi liu 15 mg
Morphin tim di da 4 gi/1 ln, cn au c ct.
Tng s Morphin chch trong 24 gi: 15 mg x 6 = 90 mg.
Nu dng ng ung th nhn cho 3: 90 mg x 3 = 270 mg v liu tim tc dng gp 3 ln
liu ung khi dng lu di.
Dng Morphin thng gy bun nn v bn nn km theo thuc chng nn
(metoclopramide 10 mg) km ch n chng to bn hoc cc loi thuc nhun trng nh :
Coloxyl vi Senna 2 vin ti, Oxid Magne 5g, ngy 2 ln.
M sng hay hoang tng l mt tc dng ph thng xy ra khi cho Morphin nhng n
s nh i khi gim liu hoc sau khi dng 1 n 2 ngy. Nu vn cn nghim trng, c th cho
Morphin di da liu thp c th lm gim du hiu ny. Nn dng phi hp xen k vi cc
thuc khc nh Tylenol hoc Codein gia cc ln tim Morphin.
+Fentanyl dn trn da: Fentanyl mnh hn Morphin gp 50-100 ln. Fentanyl
thm qua da nn c th dng di dng dn. Loi Fentanyl dn ny cung cp 1 lng thuc chm
qua da ko di n 3 ngy.
Ch nh: Dng cho bnh nhn khng th ung thuc c do nn ma, kh nut, hoc
bnh nhn c ri lon chc nng ng rut.

13
C ch hot ng: Fentanyl sau khi dn trn da s khuych tn vo lp m di da v i
vo mu. Ming dn nn dn vo vng c lp m di da nh vng bng, vng ngc trn hoc
vng mng. Ming dn Fentanyl phi mt 12 gi mi c tc dng gim au, do trong 12 gi
u phi dng cc loi gim au khc khng ch cn au.
Chng ch nh:
+ Khng nn dng nhng bnh nhn suy mn khng c lp m di da.
+ Bnh nhn b st bi v s tng hp th thuc v gy ra ng c.
+ Bnh nhn ra m hi nhiu v ming dn s khng dnh.
+ Bnh nhn ngho khng c tin mua, nn dng morphin r hn.
Mt s tc dng ph hay gp nh vi Morphin
iu tr ct cn au
Bnh ung th thng tin trin theo thi gian lm cho ngng au ngy cng tng
ln, liu iu tr khng cn tc dng gim au, do ct cn au phi tng liu thuc gim
au. Liu tng thm thng khong 10% liu iu tr.
V d: Bnh nhn ang iu tr Morphin ung vi liu 10mg /4gi
-Tng liu trong ngy : 10mg x 6 = 60mg
-Liu tng ln : 10% x 60 mg = 6mg mi 4 gi
Liu tng ng
Liu tng ng thng dng chuyn i t mt opioid ny sang mt opioid
khc. Do s khc nhau v cu trc phn t ca mi loi opioid, bnh nhn t dung np vi thuc
mi nn thuc mi c chuyn i thng thp hn liu tnh ton 25-50%.

14
Bng 1 : Liu opioid tng ng
Thuc ng ung hoc ng trc Tim tnh mch hoc tim di
trng ( mg ) da (mg )
Morphin 30 10
Codein 200 120
Hydro-Morphon 7,5 7,5
Pethidin 300 75
Fentanyl 0,1 ( mcg )
Oxycodone 20
Hydrocone
Bng 2: Chuyn i t Morphin tim sang Fentanyl dn trn da
Morphin tim (mg/24 gi) Fentanyl dn ( mcg/gi)
18-35 25
36-59 50
60-83 75
84-107 100
108-131 125
132-156 150
Chuyn i t codein sang Morphin
V d: Bnh nhn ang dng Codein 60mg/4gi nhng bnh nhn khng au, khi
chuyn sang dng Morphin chng ta tnh liu chuyn i nh sau:

15
-Tnh liu s dng Codein trong 24 gi:
60mg Codein/4gi = 360mg Codein/24gi
H s chuyn i t Codein ung sang Morphin ung nh sau:
Liu Codein x 0,15 = Liu Morphin
Nh vy liu Morphin s dng s l:
Liu Morphin = 360mg Codein x 0,15 = 54mg Morphin/ngy hoc 9mg/4gi
Liu chuyn i c tng ln 25-50% nh vy liu Morphin s dng s l
15mg/4gi
iu tr au do thn kinh:
+ Amitriptilin : Bt u vi liu 10-25mg, mt ln trong ngy vo bui ti. Liu ti a
200mg/ngy. Qu liu e da ng c tim mch.
+ Gabapentin: Bt u vi liu 300mg vo bui ti, tng liu dn sau 3 ngy vi
300mg x 2 ln trong ngy, v 3 ngy k tip vi 300mg x 3 ln trong ngy. Liu ti a
khng vt qu 3600mg/ngy.
Ngng s dng Opioid:
iu tr opioid c th ngng li khi triu chng au c gii quyt. Nu bnh
nhn s dng opioid trn 2 tun th phi gim liu dn trc khi ngng hn trnh hi chng
dng thuc t ngt (Withdrawal syndrome). Hi chng ny biu hin st, lnh run, tot m hi,
bun nn v nn ma, au co tht bng, tiu chy, au c, mt ng, chy mi nc v tng huyt
p.
16
trnh hi chng ny, liu opioid nn gim dn trong 2-3 tun trc khi ngng
hn. Khi triu chng xy ra c th dng liu opioid cao hn liu iu tr trc mt t.
Cc thuc gim au khc :
Dng Steroide: Corticosteroid c tc dng lm gim tm thi cc phn ng quanh khi u,
gim sng v co ko, do lm gim p cc m mm quanh khi u. Bng cch gim phn ng
vim ca khi u, gim sn xut Cytokines v Prosraglandins, cc cht ny kch thch cc mt tn
cng dy thn kinh cm gic gy au. V vy, Steroid c gi tr i vi bt k khi u no.
- Dexamethasone 4-16 mg/ngy ung 1 ln.
- Predmisolone 25-100 mg/ngy nn dng vo bui sng.
Dexamethasone c tc dng khng vim mnh hn so vi Predmisolone, n t gi mui
v tc dng ko di hn.
-Anticholinergic (dng trong co tht c trn ng tiu ha): Scopolamine
butylbromide 10-20mg/6-8gi.
+ X tr : Rt c gi tr gim au cc m tn thng ti ch do khi u gy ra.
+ Ha tr liu : Gp phn chnh vo vic lm gim au nh tc dng trc tip ln khi u,
lm gim au kch thc ca khi u v phn ng vim chung quanh.
+ Th thut gy lit thn kinh: l bin php trit nht i vi cn au d di. Trc ht
l phong b thn kinh tm thi bng gy t ti ch. Sau nu c ch nh, mt s phng php
nh phu thut ct b, chch Phenol hay Alcohol hay hy thn kinh bng phng php ng kh
c dng.
17
CU HI KIM TRA NH GI
1. nh gi c mc au trong ung th ?
2. Cch s dng cc thuc gim au theo tiu chun quc t ?
TI LIU THAM KHO
I. TI LIU TING VIT
1. B Y t, Bnh vin K, 1999. Hng dn chn on v iu tr, NXB Y hc, trang 15-37.
2. i hc Y H Ni, 1999. Bi ging ung th hc, nh xut bn Y hc, trang 65-80.
3. UICC, 1995.Ung th hc lm sng, trang 225-317
II. TI LIU TING ANH
1. Jim Cassidy,2002. Oxford Handbook of Oncology 2002, Pages 83-189.
2. Vincent T. DeVita, 2001. Principles & Practice of Oncology, Pages 236-296.

1
Chng XIII
IU TR MT S TRIU CHNG THNG GP
TRONG UNG TH GIAI ON CUI
Mc tiu hc tp
1. M t c mt s triu chng, hi chng thng gp bnh nhn ung th giai on cui.
2. Gii thch c nguyn nhn v xut cc phng php iu tr ph hp.
I. I CNG
Chm sc bnh nhn ung th giai on cui dnh cho ngi bnh trc khi t trn
khong 3 thng, khi m bnh tin trin c tin lng xu, m s iu tr tch cc khng mang li
hiu qu g. Trong giai on ny bnh nhn bt u xut hin mt s triu chng do di cn ca
ung th lm cho bnh nhn au n kh chu.
Mc ch ca iu tr l lm gim bt cc triu chng, em li s thoi mi, d chu cho
ngi bnh.
II. NN V BUN NN
Nn v bun nn ko di l nhng triu chng gy kh chu v thng gp nht trong ung
th giai on cui. C th c nhiu nguyn nhn gy bun nn. Cc nguyn nhn thng gp :
- Do s dng mt s thuc chng ung th, morphin iu tr gim au.
- D dy chng hi, b chn p bi khi u hoc b kch thch.
- Tt rut, bnh l gan.
- Kch thch tm l gy nn.

2
iu tr nn khng nn ch dng mt loi thuc quen thuc m phi tm nguyn nhn
gy nn v la chn thuc iu tr cho ph hp.
S chn la thuc ty theo nguyn nhn
Nguyn nhn iu tr
Thuc NSAID Bt u s dng thuc chng nn km theo thuc Opioid
1-5-5 mg haloperidol 2-3 ln/ngy
5-10 mg prochlorperazine (stemetil) 2-3 ln/ngy
Thuc Opioids (60%) Thiethyperazine (torecan) 10 mg vin, ta dc hay tim 2
ln/ngy
Ha tr liu v x tr liu Ondansetron 4 mg- 2 ln/ngy
Domperidone (motilium) 10 mg - 3 ln/ngy
10 mg metoclopramide ln n 3 ln/ngy
Cyclixine 25 - 10 mg - 3 ln/ngy
Tng p lc ni s Dexamethasone 4-8 mg 2-3 ln/ngy
Prochlorperazine 5 - 25 mg 3 ln/ngy
Trng bng y hi (do tc dng Metoclopramide 10 mg 3 ln/ngy - Steroids
ph ca thuc hoc do suy gim Domperidone (motilium) 10 mg 3 ln/ngy
chc nng gan)

Cisapride (prepulsid) 5-10 mg 3 ln/ngy
Bn v to thnh cc phn Thuc nhun trng - nhiu loi.

3
Tc rut Nu tc rut thp, n ch t cht b (x) tt v tiu ha c.
Nu tc rut hi cao, nhn n, ngm nh v ung Haloperidol
1,5-5 mg hay hyoscine butylbromide 20 mg 3 ln/ngy
Dexamethazone 8 mg truyn tnh mch
M d dy qua da bng ni soi
Ri lon tin nh Prochlorperazine 5-25 mg 3 ln/ngy
Hyoscine 1,5 mg trong 3 ngy lin tip
Lo lng ng vin, th gin
Diazepam 5-10 mg 2 ln/ngy
Truyn dch midazolam 5-50 mg/24 gi
Haloperidol 1,5-5 mg - 3 ln/ngy
Tng Ca+ mu Truyn nc
Truyn dung dch mui
Biphosphonate
Tng Ur mu Chlorpromazine 25-50 mg 3 ln/ngy
III. TO BN
To bn thng gp trong giai on cui ca bnh ung th do t hot ng, ung t nc
v ngay c mi trng chung quanh khng quen thuc. Suy yu cc c bng v sn chu lm
gim kh nng bi tit qua trc trng. Hn na, hu ht cc thuc gim au mnh, thuc phin,
4
thuc chng trm cm, thuc khng cholin gy lit nh m ri thn kinh ca rut v gy to
bn, nn cho thuc nhun trng (nu cn).
Hi k v ghi h s u n v chc nng ng rut rt cn thit, thm khm trc trng
l phn quan trng ca vic nh gi ngi bnh giai on cui. Khi to bn khng gim v
bnh nhn khng nhn bit c th gy au bng, lm au tng khp ni, tiu dm hay tiu chy
gi, tc rut, vt v v a n trm cm. gip nhu ng rut chng ta c :
1. Thuc lm tng khi lng phn
Cc loi thuc ny lm tng s kch thch ng rut vi lng dch cho vo c duy tr
u n v . Nhng i vi ngi bnh giai on cui ung vo t v cc c yu, him khi h
thch nghi v c th lm tng to bn.
2. Cc thuc lm mm phn
2.1. Lactulose
L loi thuc c tnh thm thu, n ko nc vo trong ng rut. S dng 10-30 ml 3
ln/ngy, nhiu ngi bnh khng thch v ngt ca thuc. Loi r tin hn l dung dch Sorbitol-
Sorbilax. Mt s ngi bnh thch mi ca mui Magne hn v d : MgO hay MgSO4 c cng
tc dng
2.2. Docusate
L loi thuc lm phn mm m n tc ng nh cht hot din, kch thch cc cht bi
tit v gip chng xm nhp vo phn. Vin Coloxyl 50 mg bt k ngy no m ng rut
khng thng hay cho 2 ln/ngy; 3 ln/ngy; nu bn ko di.

5
2.3. Bisacodyl
L loi thuc nhun trng tip xc, kch thch cc cht t nim mc rut. Dorolax 5 mg
2 ln/ngy hay ti.
2.4. Phenolphthalein
L loi thuc kch thch nh, lm tng cc cht tit ca thnh rut.
3. Loi thuc du
Cht du Paraffin 10-20 ml (ti) gip tng phn d dng ngi gi hay bnh nhn nng.
4. Loi thuc lm tng hot ng c trn
Senna lm tng s hot ng ca thnh rut bng tc dng trc tip ln c trn. Coloxyl
vi Senna (8 mg) vo bui ti.
Cm Senokot (15 mg cho 5 ml) v dng vin (5-7 mg) vin ta dc nh Glycerine hay
Bisacodyl (Durolax) gip kch thch s bi tit; tht tho nh git (th d Microlax) c th c
dng gia nh; tht tho vi nc m, Glycerine, du hay Phosphates c th c iu dng
thc hin ti nh theo y lnh bc s : cho 1 ngn tay c mang gng tay sch ly phn qua trc
trng, nn cho thuc gim au v an thn (nu cn). Chch Pethidine 25-100 mg tim tnh mch
(ty thuc vo kh nng hp thu thuc ca bnh nhn) v cho thm diazepam 5 mg hay
midazolam 5 mg gip ly phn d hn v khng lm bnh nhn kh chu.
IV. CC TRIU CHNG KHC
1. C chng
Trc ht cn tm nguyn nhn gy bng chng : khi u, gan to, chng hi, tc rut,
to bn. C chng do nguyn nhn c tnh c th tch t 10 lt dch hay hn na gy cng tc
thnh bng, hn ch hot ng c honh lm bnh nhn rt kh chu.

6
C th dng cc thuc li tiu lm gim c chng nh : Spironolactone 50 mg 4
ln/ngy ; Furosemide 40-120 mg/ngy c th lm gim vim chung quanh khi u v gim s
xm nhp huyt thanh vo khoang bng. Chc ht bt dch mng bng ch nn thc hin khi s
cng chng gy tc bng, kh chu, bi v chc ht dch mng bng s ly i mt s lng ln
cht m c th lm ngi bnh yu sc v suy nhc nhanh hn.
t ng ni mng bng - tnh mch ch : Thnh thong c lm trong cc tnh hung
c bit, v d : C chng nh trp do d t ng ngc
2. Kh th
Kh th thng chim 70% cc trng hp bnh nhn ung th giai on cui. Cc
nguyn nhn thng gp l cc bnh c tnh phi c th gy : chn p ng h hp, xp thy
phi hay nhim trng, tt nghn ph qun. Cc nguyn nhn ph khc nh : trn dch mng phi,
x phi, di cn phi rng, c chng, vim phi do x tr, nghn mch phi, chn p mng ngoi
tim cp.
Cn xc nh nguyn nhn iu tr cho ph hp, th d : Suy tm tht tri cho li tiu,
vim phi cho khng sinh, co tht ph qun cho Salbutamol hay thuc khng vim dng kh dung
.v.v...
3. Cc triu chng n km, kh ming
Ngoi nhng triu chng thng gp giai on cui, nhng biu hin khc nh suy
nhc, kh ming v n km l 3 triu chng d a n suy sp cho bnh nhn.
- n km :
+ Phn ln bnh nhn ung th t nhiu n ung km, a n suy nhc. Cn loi
tr cc nguyn nhn c th cha tr nh ta ming gy au ming, tng Ca+ mu, to bn, nn do
thuc. Ban u cho thuc chng nn nh Metochlopramide 10 mg 3 ln/ngy hay

7
Dexamethazone 2-4 mg/ngy s gip nhiu bnh nhn n ngon v ci thin sc khe trong mt
thi gian. Megastrol Acetate (400 mg-800 mg/ngy) gip tng s thm n nhng t tin.
+ Truyn tnh mch vi dung dch c nhiu nng lng v m thng c dng
Nam Triu Tin, Vit Nam, Nht v Trung Quc. Nhng tri li Bc M, Chu u hay c h
khng dng v t c bng chng chng minh rng s chuyn nng lng v m c th ko di
thm cuc sng cho bnh nhn.
+ Trong thc t rt c th khi khi u c nui dng tt n cng pht trin nhanh
hn.
- Kh ming : L triu chng thng gp lm bnh nhn kh chu, gy ra bi :
+ Cc yu t lin quan n suy nhc : mt nc, th bng ming, ta ming.
+ Cc yu t lin quan n iu tr : x tr vng mt, thuc an thn, thuc chng
trm cm, Phenothiazines, thuc chng co tht.
Nhm gim nhanh cc triu chng ny, cho sc ming thng xuyn 2 gi/1 ln vi dung
dch sc ming nc Soda hay Bicarbonate, iu tr nm Candida, ch ra li d mt cch nh
nhng vi mt bn chi mm v oxy gi ha long. Cung cp nc qua cc dng nh ming da
ti, nhai ko cao su, ngm ming nc nh, ung nc bng ng nh git. Tt nht cho
ngm vin sinh t C s kch thch tit nc bt nhiu hn. Cho kem Vaselin hay du thc vt
thoa mi thng xuyn. Nu ming v bn cho sc ming vi Lidocaine ha tan vi
Chlorhexidine.
8
CU HI KIM TRA NH GI
1. M t mt s triu chng, hi chng thng gp bnh nhn ung th giai on cui ?
2. C ch ca to bn bnh nhn giai on cui, bin php khc phc ?
TI LIU THAM KHO
I. TI LIU TING VIT
1. i hc Y H Ni, 2001 Bi ging ung th hc, trang 93-94
2. UICC, 1999. Cm nang ung bu hc lm sng, nh xut bn Y hc.
II. TI LIU TING ANH
1. Palliative Care in Terminal Illness-second edition 1994

1
Chng XIV
CHNG TRNH
PHNG CHNG BNH UNG TH VIT NAM
GIAI ON 2002-2010
Mc tiu hc tp
1. K c 10 loi ung th ph bin theo gii Vit nam
2. Trnh by c cc mc tiu phng chng bnh ung th t nm 2002 n nm 2010
Ngy 17 thng 6 nm 2002 Th tng Chnh Ph nc Cng ha x hi ch ngha Vit
Nam c quyt nh s 77/2002 Q-TTG v vic ph duyt Chng trnh Phng chng mt s
bnh khng ly nhim giai on 2002-2010 gm cc bnh v tim mch, ung th, i tho ng,
ri lon sc khe tm thn (ng kinh, trm cm). Trong bi vit ny chng ti xin trnh by
nhng ni dung chnh ca chng trnh phng chng ung th giai on 2002-2010.
I. TNH HNH PHNG CHNG UNG TH HIN NAY
1. Tnh hnh bnh ung th trn th gii
- Theo c tnh ca t chc y t th gii (TCYTTG) hng nm trn th gii c khong 10
triu ngi mc bnh ung th (UT) v c 6 triu ngi cht do cn bnh ny. Vn phng
chng ung th (PCUT) lun lun c coi l mt trong nhng chin lc u tin hng u v
bo v sc khe ca TCYTTG. Ung th l nguyn nhn t vong ph bin ng th hai cc

2
nc pht trin, tnh hnh mc bnh v t vong do ung th ngy cng tng, tuy nhin hn mt
na s bnh nhn ung th l cc nc ang pht trin. T l ny s tng ln nhanh cng vi s
pht trin kinh t, cng nghip ha, nhim mi trng v gia tng tui th trung bnh, d kin
n nm 2015, mi nm trn th gii s c 15 triu ngi mi mc bnh ung th, trong hai
phn ba l cc nc ang pht trin.
- Ung th khng phi l bnh v phng cu cha, 1/3 bnh ung th c th phng nga
c; 1/3 c th cha khi c nu chn on sm v cng vi vic chm sc h tr s lm
tng cht lng sng thm cho 1/3 bnh nhn ung th cn li.
- Vn phng chng ung th lun c xem l mt trong nhng chin lc u tin hng
u ca TCYTTG vi 4 ni dung:
+ Phng bnh ban u
+ Sng lc pht hin sm
+ iu tr bnh c hiu qu
+ Chng au v chm sc triu chng
2. Tnh hnh ung th Vit Nam
- T l mc bnh v t vong do ung th hng nm cha c iu kin tin hnh iu tra t
m v y trn phm vi ton quc. Tuy vy qua ghi nhn ung th H Ni (1988-1994),
thnh ph H Ch Minh (1990-1994), qua tham kho cc kt qu iu tra mt s a phng
trc y vi cc bo co PCUT Vit Nam ca mt s tnh, i chiu vi nhng thng k ung
th mt s nc trong khu vc ng Nam , so snh thang tui Vit Nam vi cc nc,
chng ti c tnh hng nm t l mi mc ung th ca ngi Vit Nam t 100.000 n 150.000
trng hp v khong 70.000 ngi cht do cn bnh ny. Trn thc t s bnh nhn ung th
c nhn iu tr cc bnh vin rt thp. Cc c s chuyn khoa c phng tin mi nhn

3
iu tr c khong 7% s bnh nhn ung th. Cc c s y t khc Trung ng v tuyn tnh
iu tr ung th ch yu bng phu thut nhng a s bnh nhn khi ti bnh vin giai on
mun nn kt qu iu tr rt hn ch.
Cc loi ung th ph bin Vit Nam (t sut/100.000dn)
Bng 2: 10 bnh ung th thng gp Nam gii

(2001-2004) (2001-2004) (2003)
Phi 39,8 1 10,8 3 29,5 1
D dy 30,3 2 14,4 2 15,3 3
Gan 19,8 3 16,4 1 25,4 2
i trc trng 13,9 4 4,9 4 16,2 4
Thc qun 9,8 5 1,7 9 4,0 8
Mi hng 7,8 6 1,5 12 4,2 7
U lympho c 7,2 7 3,8 5
Bnh bch cu 4,7 8 2,4 8 4,6 6
Bng quang 3,5 9 3,0 7
Vm hng 3,2 10 0,0 22 4,8 5
Li 1,9 14 1,6 10
M mm 2,0 14 2,9 7
4
Ty 1,2 18 1,3 14
Tin lit tuyn 2,7 12 1,0 16 2,8 10
Nhau thai 1,3 17 0,9 12
Dng vt 1,8 14 1,5 13
Da 3,0 9
Bng 3: 10 bnh ung th thng gp N gii

(2001-2004) (2001-2004) (2003)
V 29,7 1 12,2 1 19,4 1
D dy 15,0 2 7,3 2 5,5 6
Phi 10,5 3 3,6 4 12,4 3
i- trc trng 10,1 4 3,4 5 9,0 4
C t cung 9,5 4 5,0 3 16,5 2
Tuyn gip 5,6 5 1,6 10 3,8 8
Bung trng 4,7 6 2,1 9 3,8 7
Gan 4,5 7 3,4 6 6,0 5
U lympho c 4,0 8 1,4 12
Bnh bch cu 3,4 9 1,4 11 3,2 9
Mi hng 3,3 10 0,5 18
M mm 1,4 13 2,6 8

5
Da 2,6 10
- Qua bng s liu hai min th nam gii cc loi ung th hay gp ging nhau, l:
ung th phi, d dy, gan, vm hng, i trc trng; ph n ung th c t cung min Nam
cao hn min Bc.
- Nhng ung th c t l mc cao hn so vi th gii: ung th vm hng, ung th gan,
ung th d dy, ung th c t cung (min Nam).
- Nhng bnh ung th c t l mc tng i thp so vi th gii: ung th tin lit tuyn,
ung th v, ung th da, ung th i trc trng.
II. MC TIU PHNG CHNG BNH UNG TH T NM 2002-2010
T nhn thc ung th l bnh ca x hi, l vn ca mi ngi, phng chng ung th
l nhim v ca Nh nc, ca mi gia nh v ca mi ngi dn.Cn phi c chng trnh
quc gia v PCUT di s ch o hot ng ca cp Nh nc v phi hp ca nhiu ngnh,
nhiu t chc v on th x hi.
1. Mc tiu chung
Lm gim t l mc, gim t l t vong v ci thin cht lng cuc sng cho bnh nhn ung th.
2. Mc tiu c th
- Gim t l mc cc loi ung th c lin quan n thuc l xung 30% so vi nm 2000.
- Thc hin tim phng vim gan B cho 100% tr s sinh phng ung th gan nguyn
pht.
- Gim t l t vong ca mt s loi ung th: v, c t cung, khoang ming, i trc trng.
- Gim t l ngi bnh ung th giai on mun n c s chuyn khoa t 80% xung
cn 50% so vi nm 2000.
6
III. CC GII PHP
1. Kin ton mng li phng chng ung th
1.1. Tuyn trung ng v khu vc
u t nng cp cc bnh vin chuyn khoa u ngnh thnh cc trung tm hon chnh
va c kh nng thc hin cng tc phng bnh, cha bnh, nghin cu khoa hc v o to.
1.2. Tuyn tnh
Thnh lp cc khoa ung bu trong bnh vin a khoa tnh hoc cc bnh vin chuyn
khoa ung bu thc hin tt vic khm, iu tr v phc hi chc nng cho bnh nhn ung
th, gim gnh nng qu ti cho cc Bnh vin tuyn trung ng. Trung tm y t d phng, trung
tm phng chng cc bnh x hi v trung tm truyn thng gio dc sc khe c trch nhim
thc hin cc hot ng lin quan cng tc phng bnh ung th.
1.3. Tuyn huyn, x
Tp trung ch yu vo cng tc phng bnh ban u, ch trng n vic truyn thng gio
dc cho nhn dn bit cch phng chng v t pht hin sm mt s du hiu ca bnh ung th
kp thi gi bnh nhn ln tuyn trn chn on v iu tr.
2. Lng ghp hot ng ca chng trnh PCUT vo chng trnh phng chng cc bnh khng
ly nhim
Mc ch tit kim ti a ngun nhn lc, vt lc v ti chnh, nng cao hiu qu hot
ng ca chng trnh. Cc hot ng bao gm:
- y mnh vic thc hin cc bin php phng bnh ban u v gio dc sc
khe: y l chin lc kh thi v hiu qu nht i vi nhiu loi bnh trong c ung th.
7
Phng bnh ban u tp trung vo vic gii quyt cc yu t nguy c gy ung th nh: ht thuc
l, ch n khng hp l, nghin ru, an ton tnh dc, sc khe sinh sn...
- Ht thuc c xem l yu t nguy c quan trng nht gy bnh ung th Vit
Nam. Chng ht thuc l c th lm gim 30% cc loi ung th ngi nh: ung th phi, ung
th ng h hp, tiu ha trn, ung th d dy, ung th ty, ung th bng quang.
- Vai tr ca dinh dng vi cc bnh ung th l rt r rng. Ci thin ch n
ung bng cch gim hp thu cc cht bo ng vt, trnh s dng thc phm c nhim thuc,
nhum mu cng nghip, thuc tr su dit c, thc phm mc v nn tng cng tiu th nhiu
rau qu.
- Tuyn truyn gio dc nhn dn nng cao nhn thc v phng nga v pht hin
sm ung th, c bit gio dc nhng bnh nhn ung th v cc du hiu bo ng ca bnh
pht hin sm v iu tr sm nhm gim t l t vong.
- Lng ghp phng bnh ung th vi phng cc bnh khng ly nhim tuyn y t
c s trong vic thc hin chm sc sc khe ban u.
- Gio dc v li sng lnh mnh trong cc chng trnh y t, trng hc, bnh
vin, ni lm vic...
- Phi hp chng trnh tim chng quc gia thc hin tim chng vaccine
vim gan B cho 100% tr mi sinh.
- Pht hin sm, nng cao hiu qu iu tr, chm sc, phc hi chc nng cho
ngi bnh ung th.
- Cng nh cc cng tc phng bnh ban u, vic chn on, iu tr chm sc,
phc hi chc nng cho ngi bnh cn lng ghp ti a nhng kh nng c th gia cc bnh
thuc nhm bnh khng ly nhim c lin quan cht ch vi nhau.

8
- Chn on sm cn c tin hnh ti cng ng theo hnh thc lng ghp vi
chng trnh dn s k hoch ha gia nh, chng trnh chm sc sc khe b m tr em,
chng trnh khm sng lc cho cc i tng c nguy c cao nhm pht hin sm mt s ung
th nh: ung th v, c t cung, da, khoang ming, i trc trng, qua vic pht hin cc du
hiu bo ng ung th.
3. Cng tc iu tr
- Tp trung nng cao cht lng v hiu qu iu tr ung th. Hin nay cng tc ny ch
yu tp trung tuyn trung ng nn cc bnh vin lun trong tnh trng qu ti v vy cn ch
trng nng cao trnh chuyn mn, u t trang thit b cho c tuyn trung ng v a phng
nng cao cht lng chn on, iu tr cho ngi bnh.
- Nghin cu, theo di, gim st, nh gi dch t hc v trao i thng tin: thnh lp cc
n v nghi nhn thng tin cc tnh, thnh ph ln nh H ni, thnh ph H Ch Minh, Hu,
Nng, Thi Nguyn, Hi Phng, Cn Th... tin ti cc tnh trong ton quc phi t chc ghi
nhn ung th nh gi t l mc, cc c im dch t hc ung th mi a phng.
- Nghin cu hon chnh cc phc iu tr ung th ngang tm vi cc nc trong khu
vc.
- Nghin cu m hnh chm sc bnh nhn ung th giai on cui, chng au v chm
sc triu chng ti cng ng.
- o to v pht trin nhn lc chuyn ngnh ung th, tuyn truyn hng dn, cho nhn
dn hiu v ng dng cch phng chng mt s bnh ung th.

9
4. Gio dc v o to
- L cng tc quan trng ca chin lc v cn c s phi hp cht ch, ng b vi cc
trng i hc, cao ng, trung hc y dc trong c nc gio dc nhng ngi lm cng tc
chuyn mn chm sc sc khe, c bit nhng cn b y t trong lnh vc phng chng ung th.
- Cn xy dng cc chng trnh o to a dng, ph hp cho cc cp khc nhau v
xy dng h thng ti liu chun thng nht v hng dn chn on, iu tr v phng bnh ban
u i vi bnh ung th.
- Xut bn ti liu chuyn mn cho cn b y t v hng dn chn on v iu tr ung
th.
- Xut bn ti liu tuyn truyn ph bin kin thc cho nhn dn vi ni dung d hiu v
thc t h c th hiu v ng dng cch phng chng mt s bnh ung th.
5. Xy dng chnh sch trong lnh vc phng chng ung th
- Lut v phng chng tc hi ca thuc l, v sinh an ton thc phm, phng chng cc
bnh ngh nghip, an ton bc x... nhm hn ch ti a nguy c mc bnh, t vong, ng thi
c chnh sch u i i vi ngi bnh.
- Huy ng s tham gia tch cc ca cc B, Ngnh v cng ng trong cng tc PCUT.
6. Tng cng hp tc quc t
M rng, nng cao hiu qu hp tc quc t song phng, a phng vi cc nc, cc t
chc quc t, t chc phi chnh ph trong lnh vc phng chng cc bnh khng ly nhim.
IV. KINH PH THC HIN
Ngn sch thc hin chng trnh PCUT bao gm cc ngun:
- Ngn sch nh nc.

10
- Ngun h tr ca cc t chc trong v ngoi nc.
- Vn vay t ngun ODA v cc qu h tr pht trin trong v ngoi nc (nu
c).
- Ngun ng gp ca ngi bnh di hnh thc vin ph v bo him y t.
VI. T CHC THC HIN
Chng trnh phng chng bnh ung th c chia ra lm 2 giai on:
1. Giai on 1: t 2002 2005
Tp trung vo:
- Thit lp v cng c mng li PCUT, trong tp trung u tin cho cc thnh ph ln,
khu th.
- Xy dng chng trnh o to, bin son v pht hnh h thng ti liu chun hng
dn chn on, iu tr v phng bnh ung th.
- T chc tp hun, o to mi, o to li, nng cao trnh cho i ng cn b y t t
trung ng n c s.
- iu tra lp bn dch t v bnh ung th trong phm vi ton quc.
- Trin khai cng tc gio dc tuyn truyn v phng bnh v pht hin sm cho cng
ng.
- T chc khm sng lc pht hin sm v iu tr cho bnh nhn ung th ch yu cc
thnh ph ln.
- Ban hnh cc vn bn php quy, chnh sch h tr to iu kin cho vic thc hin
chng trnh PCUT.

11
2. Giai on 2
T 2006-2010:
- Hon thin mng li PCUT v qun l bnh nhn ung th t trung ng n a
phng.
- o to nng cao trnh c v phng bnh cng nh khm cha bnh cho ton b i
ng cn b thuc mng li PCUT.
- Trin khai pht hin sm, iu tr v t chc phng bnh trn phm vi ton quc.
CU HI KIM TRA NH GI
1. K c 10 loi ung th ph bin theo gii Vit nam ?
2. Trnh by cc mc tiu phng chng bnh ung th t nm 2002 n nm 2010 ?
TI LIU THAM KHO
I. TI LIU TING VIT
1. Nguyn Chn Hng. 2004. Ung bu hc ni khoa. Trang 194-206. Nh xut bn y hc.
2. Phm Thy Lin. 1999. Tnh hnh ung th Vit Nam. Trang 16-44. Nh xut bn Nng.
II. TI LIU TING ANH
1. Oxford Handbook of Oncology. 2002. Epidermiology of cancer. pp 3-11.

1
THNG TIN V TC GI GIO TRNH
1. H v tn: PHNG PHNG
Nm sinh: 1958
C quan cng tc: B mn Ung Bu Trng i hcY Dc Hu
a ch Email: phuongem@yahoo.com
2. H v tn: NGUYN VN CU
Nm sinh: 1966
a ch Email: nguyenvancau2008@gmail.com
3. H v tn: NGUYN TRN THC HUN
Nm sinh: 1980
a ch Email: drthuchuanonco@yahoo.com.vn

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1

Trong thi i ngy nay mc d khoa hc c nhng tin b vt bc c bit l trong

Tuy nhin chng ta c th nh ngha ung th nh l qu trnh bnh l trong mt s t

ny c kh nng xm ln v ph hy cc t chc chung quanh. ng thi chng di tr v n

- Tin trin nng dn tin n ri lon chc nng ca cc c quan do khi di cn nh

thiu nng h hp, suy chc nng gan thn.

II. QU TRNH TIN TRIN T NHIN CA UNG TH

tr th s din bin qua cc giai on sau:

Thng xy ra rt nhanh, sau khi cc t bo tip xc vi cc tc nhn gy ung th: tc

nhn vt l, tc nhn ha hc, tc nhn virus. Cc tc nhn ny gy ra thng tn DNA ca t

1.2. Giai on thc y

Do tip xc lin tc, ko di vi cc cht gy ung th lm n nh v duy tr thng tn

Bc khi u v giai on thc y chng ta ch bit c qua m hnh th nghim v

nhng nghin cu v dch t ung th ngi.

1.3. Giai on tin trin

Hnh 1: S giai on khi u

d phng giai on khi u sinh ung th ngi ta phi bo v trnh tip xc vi cc

2. Ung th tin trin

trin cc b ti ch, xm ln ti vng v cho di cn ton thn.

+ Sng lc v iu tr cc thng tn tin ung th.

+ Sng lc v iu tr nhng ung th kch thc cn nh (ch yu bng phu thut

hoc tia x).

+ iu tr tch cc cc ung th ang cn ti ch (thng kt hp vi iu tr h tr

ha tr liu hoc ni tit tr liu).

Hnh 2: Cc giai on tin trin ca ung th

Di cn ung th l tnh trng cc t bo ung th tch ri ra khi u nguyn pht n c

Di cn theo ng bch huyt

hng v hch v tinh

[2] Hch phn ng tiu dit t bo ung th

[3] T bo ung th li trong hch khng c phn ng

[4] T bo ung th chy qua hch v tinh m khng c phn ng c hiu

[5] T bo ung th pht trin v xm nhp hch bch huyt

[6] T bo ung th ph v v v xm ln t chc chung quanh

[7] T bo ung th lan n hch k cn

[8] Tc gy ph n bch mch

huyt n hch v tinh.

2. Phn ng ca h bch huyt c th tiu dit cc t bo ung th.

3. T bo ung th li trong hch bch huyt m khng c phn ng g, gi l di cn vi th.

4. i khi t bo ung th i qua hch v tinh m khng c phn ng c hiu no

hiu (hch cng, khng au, c nh).

6. Hch c nh l do t bo ung th ph v bao v xm ln ti cc t chc chung quanh.

7. Cc t bo ung th c th di tr ti hch k cn to ra hin tng vim h bch huyt dng

ung th (carcinomatous lymphangitis).

+ Cc loi ung th ca t chc lin kt (ung th xng, ung th phn mm)

thng di cn theo ng mu n cc tng xa nh gan, phi, no.

Hnh 5: Ung th di cn theo ng mu

+ Di cn hay i dc theo mch mu v thn kinh, theo li t b cn tr, in hnh l

ung th d dy lan qua lp thanh mc vo bng gy di cn bung trng.

+ Dao m, dng c phu thut c th gy gieo rc t bo ung th ra ni khc trong

phu thut nu m trc tip vo khi u.

III. D PHNG UNG TH

Mc du c nhng tin b rt ln trong lnh vc iu tr ung th trong hai thp k qua,

nhng ung th vn cn l mt bnh kh c th iu tr khi.

th l mt vai tr mi rt quan trng i vi tt c cc thy thuc trong th k 21. ch ng

sch phng chng tch cc phi da vo c s kin thc khoa hc.

Ngi ta chng minh c thuc l gy ra nhiu loi ung th:

+ Bng cc nghin cu v dch t hc.

+ Bng nhng nghin cu v thnh phn cha trong thuc l.

+ Bng s khm ph ra s thng tn gen c hiu ca t bo khi u v t bo

bnh thng nhng ngi ht thuc.

+ Bng s pht trin nhng kin thc c bn v s chuyn ha ca amines ca

Qua nghin cu dch t hc v sinh hc c s lin quan r rt gia thuc l v cc ung th

cht, mt s ha cht chnh gy ra ung th: