Negay ban hin: / (2023 S6 trang: PHAC DO DIEU TRI UNG THU THUC QUAN Lan ban hinh: Bién soan Tham xét Phé duyét Ho vatén UU Lé THAI BINH KHANG VO ptiC CHIEN Chiredanh | PhY wae Ngoai |) rp. kéhogch ting hop jm Dée Chit ky 1 MucTiEU; - Phe d6 duoc thiét lap nhim théng nat trong chin doan va dieu tri ung thy thu quan, gop phan 1. Phac d6 diroc ap dung cho I. A chuan héa va nang cao PHAM VI AP DUNG Gu qua digu tri. ca bénh nhan duoe chan Goan ung thu thre quin. NHIEM sing tudn thi quy trinh thu hign xét nghiém, chan dodn, diéu tri theo phae d3. - Digu dudng khoa lim sing chiu tréch nhiém thyc hign y lénh. TAILIEU THAM KHAO Y 18 (2020). Ung thu thure quan. Huéng din chan doan va diéu tri mét sé bénh ung buéu. Nha ‘xuat ban Y hoe, tr: 264-280. 2. Bénh vién Cho Réy (2018). Ung thu thy quan. Phéc dé diéu tri 2018 (phan ngoai hoa). Nha xuat ban Y hoe, tr: 802-819. 3. Frederick L Greene et al (2018). Oesophagus. AJCC Cancer Staging Manual 8th Edition. Springer. 4, National Comprehensive Cancer Network (2020). Esophageal and Esophagogastric Junction Cancers, version 5.2020. NCCN Clinical Practice Guideline in Oncology. ‘TU ier TAT UTTQ ‘Ung thu thye quin AICC. Uy ban lién hop vé ung thu Hoa Ki EMR Cit bo niém mac qua néi soi ESD Cit bé dui niém qua néi soi NCCN Mang luéi ung thu quéc gia Hoa Ki VI. NOLDUNG 1. DAICUONG |. Dinh nghia . ‘Ung thu thue quan (UTTQ — C15) 1a khoi u ac tinh x hai loai: Bigu mé gai va biéu mé tuyén. Theo GLOBOCAN 2018, c6 khoing 500.000 ca direc chin don méi va 450.000 Vit Nam, ung thu thuc quan dimg thir 15 trong nhimg bénh ung thy thing gip phat tir cae té bao biéu mé thuc quan, gom it vong. Tai vi 2.411chan doan moi, 2.222 ca tir vong méi nam va tyle mic 8,7/100.000 dan. D9 tudi mac thudng gap nhit la khoang 50 dén 60 tudi. Ung the thire quan 1a m6t trong nhiing ung thu ¢6 tién Ivong rat x4u. Bénh thutng phit hign 6 giai doan muén nén viée diéu tri ung thir thuc quan rat khé khan, tién Ivong va két qua thuimg xu. 2. Nguyén nhin . Nguyén nhan khong 16 ranj hit thude la, trdo nguge da day thye quan, thye quan Barrett, thira cn béo phi, thiéu mau dc tinh, tién cin xa tri, d6t bién gen. 3. Phan chia thye quan Cac yéutd nguy co bao gon Bang 1: Phan chia thye quan Tén theo Khoang cach jai phau (cm) Thue quin [Trén | Hahiudénhomite | 15 dé <20 cé Thye quan [Trén | HomiedénTMdon | 20 dé 25 ngue Gitta | Bo duéi TM don dén | 25 dén <30 TM phéi dusi Duéi | Bi dudi TM phéi duéi | 30 dén <40 dén EGI Thye quan [Dudi | EGIdén2emdusi | 40 din 45 bung 4, Phin giai doan ung thir thye quan (theo AJCC 8th) 4.1. Phan loai TNM T: — Unguyén phat TX: U nguyén pl TO: —Khéng cé bing chimg ciia u nguyén phat Tis: Loan sin cao, 16 bio de tinh gidi han trong lép biéu mé duoc gidi han béi mang diy At khéng danh git duce Tl: Uxim lin 16p dém niém mac, co niém hoae duéi niém Tia: U xim lin lp dém hole eo niém Tb: U xim lin lop duéi niém 2: U xim lin t6i lép co 13: U xm lan t6i lép thanh mac T4:U xi lan cdu trie xung quanh T4a: _XAm lin ming phéi, mang tim, tinh mach don, cx honk hoi phiic mac T4b: Xam lan cau triie khac nhwr déng mach chi, than d6t s6ng hoe khi quan N: — Hach ving dicin NX: Hach ving di can khong dinh gid duge NO: Khéngcé di cin hach ving NI: Di can | hode 2 hach ving N2: Di cin 2 dén 6 hach ving N3: Di can 7 hach ving tra len M: Dicdnxa MO: Khéngcé di cin xa ML: Cédicinxa G: DO bigt hoa GX: Khéng danh gié duge dé biét hoa Gl: Biét hod tét G2: Biét hod trung binh G3: Biét hoa kém, khéng biét hoa4.2. Xép giai doan * Ghi chi: 6i véi ung thu té bao gai, vi tri u déng vai tr quan trong trong viée xép giai doan. Méc xée dinh vi tri la trung tam ciia khéi u. a) Ung thu té bao bit mé gai Bang 2: Phin giai dogn theo Lim sang T eN M 0 Tis NO MO. I TI NO-1 MO 1 12 NO-1 MO 73 NO MO 1 73 NI MO TI3 N2 MO. IVA 14 NO-2 MO Bat ky N3 MO IVB Batky Bat ky Bang 3: jiai doan theo giai au mo Gini dogn | pT pN_ [pM 0 Tis No__[MO IA Tila |No_| MO 1B Tla__|No__[ MO 1B Tib__|No__| Mo 1B 12 No__[ Mo TA T2 No___[ Mo A 13 No__| Mo A, T3 No__[ Mo Gittal tren) TB, T3 No__| Mo Gittal tren) 1B, T3 No__[ Mo 1B. Tl Ni [Mo THA Tl N2__| Mo THA T2 Ni___| Mo 1B 12 N2__[ Mo 1B, T3 Ni2 [Mo 1B T4a__| No-1_| MO IVA T4a_ [N2__| MO IVA Téa NO-2_[ MO IVA Baky [N3_ [Mo IVE Batky | Batky [MI ¥ Bang 4: Phan giai dogn sau khi dieu trj tan hd try Giai doan ypT ypN ypM 1 10-2 NO Mo 1 73 NO MO THA T02 NI MO 1B T3 NI MO 1B T0-3 N2. Mo 1B T4a NO MO IVA T4a NI2 MO IVA T4a Nx MO IVA Tab NO-2 MO IVA Batky N3 MO IVB Bat ky, Bat ky MIb) Ung thy té bao biéu mé tuyén theo Him sing N 3em, biét hod kém); eT1b-cT2, N+ hodc ¢T3-eT4a, N bat kj true mé, sau dé: + Cit thue quan néu cin u dai thé va khéng ¢6 bing chimg di cin + Theo doi hode cit thre quan (itu tin) néu khGng con w dai thé + Ukhong thé ct bo hoac di can: diéu tri giém nhe Hoa xa triét dé he hoa don thudn néu u xm Hin khi quan, mach ma i tiép theo sau phiu thudt trigt dé Bénh nhan chwa diéu tri tin hé tre thu u<3em, biét hoa tét, thu quan nguc bung): Loa xa tri lén, tim + Néu béret R2: Iua chon hod xa tri hay chi cham séc gidm nhe Bénh nhan da. tri héa xa tan hé tro + Neu bé cat RO va: * ypT0,NO: theo doi dinh ky © yp. T(+) val hoic yp N(+): Nivolumab, + Néu ba edt R1; R2: theo ddi t6i khi tién trién hode chim sée gidm nheDieu tri tai phat sau theo doi Tai phit tai ché tai viing (48 mé; chua héa xa true dfiy) H6a xa déng thdi: hoc héa tri; hodc chim séc gidim nhe Tai phat tai ché tai ving (héa xq truéc day khong mé) Cit thuc quan néu edt duoc va the trang bénh nhin cho phép Tai phat di can xa His tri; hoe chim sée gidm nhe 1.2. Ung thr biéu mé tuyén. - pTis, pT1a hoge pT1b non; C6 cde lua chon: + Cit tiém mac qua néi soi (EMR hoic ESD): wu tién + Cat thure quan =pTIbNO: — Cat thue quan - eT1b-cT2,N0 (t6n thutong nguy co thap: u <3em, biét hoa t6t, thu quan ngue bung): — Cat the quin - eT2N0 (nguy co cao: > 3em, biét hoa kém); eTIb-cT2, N+ hoc ¢T3-cT4a, N bit ky: Hod xa tri truée mé hoc hod tri truée mé, sau d6: + Ct thre quan néu cin u dai thé va khéng cé bing chimg di cin + Theo doi hoa cat thye quan (uu tién) néu khéng con u dai thé + U khing thé cit bé hode di cn: diéu tri giim nhe hoa don thuan néu u x4m lin khi quan, mach mau lén, i tiép theo sau phiu thuat triét dé Bénh nhan chwa diéu tri tan hé tre + Néu bi efit RO va: © Hach am tinh © pTis, PTI: _ theo doi dinh ky © pT2: theo dai hoje cdn nhc hoi xa tri cho BN nguy co cao © pT3,pT4a: thee doi hodc can nhc hos xa tri hode héa tri * Hach durong tinh: theo d&i hoie ein nhie hos xa tr h hoa xa tri + Néu bé edit R2: Iya chon hod xa tri hay chi chim séc gidm nhe u tri tan hé tro’ tim ic héa tri yp TO, NO: theo di hoic héa tri cho dit chu ki yp T(+) va/ hoie yp N(+): Nivolumab néu héa xa tién phdu; hoie theo di; hode héa tri tiép cho dit chu ki RI Hoa xa tri néu khong c6 xa tién phdu; hodc theo doi; hoc mé lai. R2: Hod xa tri néu khéng cé xa tién phau hay chi chim séc giam nhe i tai phat sau theo dai | Tai phit tai ché tai ving (da mé; chua héa xa trude diy) Hoa xa déng thoi; hoa héa tri; hoc cham séc giam nhe Tai phat tai chd tai ving (héa xa truéc day khong mé) CAt thye quan néu Tai phit di cin xa Hoa tri; hoe chm sée giim nhe 2. Ngoai khoa 2.1 Digu trj qua nGi soi Giai doan sm chi chiém mét ti Ié nhé trong ung thu thye quin ~ Khi ung thu chi 6 16p niém mac va khéng c6 di can xa ( Tla, NO,MO), phuong phép chon Iya diu tign la digu tri cit bé niém mac qua ndi soi ( endoscopic mucosal resection = EMR ) vi la phutongphap it xam lan, an toan, chat long cuéc s6ng dam bao va tién luong lau dai tot. ~ M6t ky thudt khée 1a cit bé duréi niém qua ndi soi ( endoscopic submucosal dissection = ESD) ciing thudng duoc ap dung vi gitip loai bé hoan toin budu véi ti 1é cao hon (92.7% so vi 52.7%) va tilé tai phat tai ché thap hon ( 0.3% so véi 11.5 %). ~ Véi giai doan buéu cao hon, phiu thudt tiéu chudn la ct bo thure quan , vi véi T1b ( submucosal tumour) 6 17-26% nguy co di cin hach, dic bigt khi budu biét héa kém, 6 xém Lin mach méu — bach huyét. 2.1 Phiu thudt trigt dé: ct thye quin Phiu thuat mi hodc ndi soi nguc bung: ~ Cat toan b6 thye quan qua 3 duéng: ngue phai, bung va cd - Tao hinh thay thé thye quan bing da day, dai tring hoe ruét non, - Nao hach 3 ving bao gém nguc, bung va cé tuy giai doan ung thu ~ Miéng néi the hién 6 co - Tuy trong hop cé thé thyc hign thém thu thuat mé rong mon vi, mo hong trang nudi an. Céc lya chon k§ thugt kha tuy theo trudmg hgp ey thé (hue quan qua khe hodnh thie quan é ~ Cit thy quan qua nga nguc, bung véi miéng ndi éngye - Cit thy quan qua khe hoanh, miéng néi trung that sau thyc hign qua ng 2.2. Phiu thugt (hoc tha thugt) tam by Ap dung khi qua chi dinh phau thuat triét dé hode hé tro dinh dung duémg tiéu hod trong thai gian digu tri tan hé tro (6 nhiing trudng hop u gay tic nghén khéng thé n uéng) - MG da day hodc hong trang nuéi an (mé hodc néi - Néi tit bing éng da day hoae dai trang lén trén khéi u qua dung sau xurong ite hoac ducéi da - Dit stent thue quin 3. Hod xa tri hd tro 3.1. Tan hé tro - Xa tri hoe hod xa tri: gi bénh nhan t6i cors6 khac Cie trudng hop béah tai ché tai ving (¢T3-4 hoe cN1-3 M0). Xa tri ngoai 41,4 Gy/23 Lin/4,5 tuin + héa tri Paclitaxel liéu SOmg'm2 va Carboplatin AUC 2mg/ml/phiit mdi tuan trong 5 tuan lién tiép. Phau thuat cat thue quan va hach viing duroc thyc hién sau 6 tun. ~ Hoa tri: Phic dd 5-FU- oxaliplatin Oxelipaltin 8Smg/m2, truyén tinh mach ngay | Leucovorin 400mg/m2, truyén tinh mach ngay 1 5-FU 400mg/m2, truyén tinh mach ngay | 5-FU 1.200mg/m2, truyén tinh mach trong 22 gity ngay | va 2, Chu ky 14 ngay, 3 dot truée PT vi 3 dot sau PT Phie dj FLOT Docetaxel S0mg/m2, truyén tinh mach ngiy | Oxalipaltin 8Smg/m2, truyén tinh mach ngay 1 Leucovorin 200mg/m2, truyén tinh mach ngay 1 5-FU 2,600mgim2, truyén tinh mach cham ngay 1, kéo dai 24 gids Chu ky 14 ngay, 4 chu ky truée PT va 4 chu ky sau PT. Phac dé 5-FU - cisplatii Cisplatin 80mg/m2, truyén tinh mach ngdy 1 5-FU 800mg/m2, truyén tinh mach chim ngay 1-5 Chu ky 21 ngay, truyén 2 chu ky truée PT Phac dé Docetaxel — cisplatin — SFU Docetaxel 70mg/m2 tuyén tinh mach ngiy 1 Cisplatin 70mg/m2 truyén tinh mach ngay 1 5-FU 750mg/2 truyén finh mach cham ngay 1-5 Chu ki 21 ngay/ truyén 3 chu ky trude PT3.2. Sau phiu thuat ~ Xa tri hoe hod xa tri: gti bénh nhan t6i cor sé khée Chi dinh cho nhing trang hop carciném té bao gai hoa carcindm tuyén cn s6t té bio u vi thé, (RI) hode dai thé (R2) ma trude 46 chwra durge héa xa tri déng théi. Doi v6i nhém carciném tuyén chi dinh héa xa tri .on duoc chi dinh cho tinh huéng pT3, T4 hoie pN (+). Xa tri ngoai 50,4 Gy/28 lan/ 5,5 tuan + héa tri Cisplatin liéu 75 mg/m? va 5-FU liéu 1000 mg/m2/ngay, thue hign 4 chu ky cich nhau mai 4 tun. ~ Hod tri: phac d6 twong ty phic dé tan 4, Diéu tri nhim trac dich - Trastuzumab: UTTQ giai doan tién trién; tai phat; that bai v6i cdc bién phap diéu ti Khic; HER2 duong tinh. + Cich ding: két hop véi hé + Liéu luong: 8mg/kg, truyén tinh mach ngay 1, chu ky 1. Sau d6 6mg/kg, truyén tinh mach ngay 21; chu ky 21 ngay. ~ Ramucirumab: 1a mét khing thé don ding khing lai VEGFR-2, thude duve chi dinh cho UTTO, ung thir migng n6i da day-thue quan tién trién sau khi that bai y6i héa tri. + Liéu ding: Ramucirumab 8mg/kg, truyén tinh mach ngay 1. Chu ky 2 tuin. 5. Diéu tri mién dich - Voi nhitng bénh aban c6 bat thuong MMR hoc cé biéu hign MSI cao thi c6 thé sir dung ligu phap mién dich v6i pembrolizumab. ~ Dieu tri bude 2 véi UTTQ biéu mé tuyén va carciném tuyén chd néi thyre quin-da day 6 bigu hién PD-LI véi chi s6 CPS >10%. - Liéu ding: Pembrolizumab 200mg/ngay, truyén tinh mach ngay 1. Chu ky 21 ngiy 6. Digu trj trigu ching, dinh duing cho béah nhiin: ~ Mi théng da da - Dinh dudng bing dutng truyén. ~ Trong qua trinh phéi hop da phuong thite diéu tri UTTQ, thudng xuyén phai quan tim t6i van dé dinh duéng va viém thye quan. - Thite an nhiéu dinh dudng mém, xay nhuyén, Sn nhiéu bita trong ngay, truyén tinh mach thém céc loai dich dinh dudng bé sung. Néu bénh nhan khéng Jn dwroc, t6t nhat nén nudi dudng qua duéng mé théng da day hoe rust non. boc niém mac thye quan, thudc tre ché loét niém mac thie quin. to dich vi chéng viém 'H CHAM SOC sau phiu thuat ct thie quan - 24 gid: nim tai hau ph, béi hoan nuée dién giai, chup X quang nguc thing. - 48 gid: rit théng tiéu, dinh dudng dung tinh mach + qua ng mé héng tring, tap théi bong bing, tip van dong. . - 72 gid: Rit din luw ngue néu tha t6t va phéi né t5t (lam sing va X quang), rit thong mili da day, giam dinh dudng tinh mach, ting dinh dudng qua dung tiéu hod, tiép tuc tap hé hip, van dong. Ney 4-7; tip an long qua dudng migng (chup edn quang tan rong nude kiém tra xi 6 tude néu in), sinh hoat van déng dan tré Iai binh thuréng. Rutt 6ng nudi Zn hong tring (néu c6) va xuat vién khi khéng cin dau higu nguy hiém va khong cn hé tro y t8 dic biét.VL. TIEN LUQNG BIEN CHUNG Biing 8: Séng thém 5 nim cia ung thu thye quan Giai doan Séng thém 5 nam 0 >95% \ >80% 1A 50-80% IB 10-30% MW 10-15% Iv <5% Theo doi va tai khiim: Nam 1 2 3 4 5 Than | 3) 6/9/12 | 15 | 18 [21 | 24 | 27 |30 | 33 | 36 | 42 | 48 | 54 | 60 2 Lim |= = f= t= f= f= || [= f= l= f= l= [= sing Noi |= = y= t= l= = = l= ]= = /= sis |=)=l=|= = [= [= [= = = l= == |= am. a = T= = = = = = = Bigu dd 1: Lich theo dai va tai Kham * Ghi chi: ic XN mau 1g Hién quan va - Lam sing: hoi bénh, kham lim sa - Noi soi: ndi soi thure quan da day wu mit c6, bung, 6, ngue, bung ~ Sigu am: sigu am - CT scan: khao s:Ngiy ban hinh: 1/2023 Sé trang: PHAC BO DIEU TRI UNG THU DA DAY Lan ban hinh; Tham xét Phé duyét Ho va té ____ BS.CKI. _ BS.CKI ove ten J Lé THAI BINH KHANG VO ptiC CHIEN Chiredanh | PAY nae Ngoai |) rp. kéhogch ting hop jm Dée Chit ky 1 MucTiEU; - Phac dé dugc thiét lip nhiim théng nhat trong chin doan va digu tri ung thu da diy, gop phin chuan hoa va néng cao hiéu qua dicu tri. I. PHAM VEAP DUNG Phac d6 duroc 4p dung cho tat ca bénh nhan duoc chan dodn ung thu da day. 1. TRACH NHIEM - Bac sing twin thi quy trinh thu hign xét nghiém, chin dodn, diéu tri theo phic 3. - Diu dudng khoa lim sing chiu trich nhiém thyc hign y lénh. IV. TALLIEU THAM KHAO Y té (2020). Ung thu da day. Huéng dan chan doan va diéu tri mot s6 bénh ung buéu. Nha ‘xuat ban Y hoc. 2 Phac do diéu tri ung thu da day cia DHYD 2021. 3. Gastric cancer: ESMO Clini 4. National Comprehensive Cancer Network (2020). Gastric Cancers. NCCN Clinical Practice Guideline in Oncology. 5.ISCCR 2019 Practice Guideline for diagnosis, treatment and follow-up 2017 TU VIET TAT UTDD _| Ung thu da day AICC Uy ban lién hop vé ung thy Hoa Ki EMR Ct bo niém mac qua néi soi ESD Cit bo duéi niém qua néi soi NCCN Mang lui ung thu quéc gia Hoa Ki HP, Helicobacter Pylori NGS Giai trinh tw gen thé hé méi MSI Bit én dinh vi vé tinh MMR Khiém khuyét sita chita bat cp saiVL NOILDUNG I. DAI CUONG 1. Dich té . . Ung thu da day (UTDD) li mt trong nhimg bénh ung thu (UT) phé bién nhat trén thé gigi. Nam 2018, ude tinh trén thé gidi cé 1.033.700 truéng hop ung thir da day mic méi va hon 782.600 tudng hop tir vong. Tai Viét nam theo Globocan 2018, UTDD diing thir 3 6 ca hai gidi sau ung thu gan va ung thu phoi véi.ty 18 mic chuan theo tudi la 11,38/100.000 dan. Trong 46, loai ung thir biéu mé tuyén chiém cho yéu (90-95%). UTDD cé tinh chat ving mién r rét lién quan t6i ché dé an udng vi béo quan thye phim. Phin bé Khong d6ng déu theo khu vuc dia ly va thoi gian. Ty 1é mic bénh thudng 6 d6 tudi cao, hiém gap 6 nhiing agi bénh durdi 30 tudi, nam gidi chiém ty Ié cao 6 tat cd cde quéc gia trén thé gidi véi ty 1g gip 2- 4 lin so véi nit gidi. Vi tri hay gp & ving hang mén vi (chiém 60-70%), sau dé la 6 ving a cong nhé (18-30%), cde ving khée it zip hon nhur ba cong ln khoing 3%, day vi 12%, tam vi 9%, UT toan b9 da day chiém 8-10%. Theo nghién citu gan day 6 Nhat Ban va Chau Au cho thay UT ving tim vi cé chiéu huéng ting lén. Ty 18 UT tim vi tir 25- 55%, UT than vi va hang mén vi tir 45-75%. 2. Yéuté nguy co” 2.1. Yéu t6 moi trudng vi ché dp an uéng ‘Moi trudng sng va ché dd ain udng d6ng vai tro quan trong lién quan 161 UTDD. Cae yéu t6 6 thé Tim ting nguy co mac UTDD gom: ~ Sir dung him luong mudi cao trong thite 3 6 chita ham Iuong nitrat cao - Rurou, thu Cc thite &n tuoi, hoa qua tuoi nhur cam, chanh, nhiéu chat xo, thife an giau vitamin A, C, cde yéu t6 vi lrong nhurkém, ding, sit, magié, ... e6 tic dung lim gidm nguy co mic bérh. 2.2. Vai trd ciia Helicobacter Pylori (HP) trd cia H.pylori trong UTDD da duoc chimg minh. Cac nghién citu cho ring H.pylori gy viém niém mac da day din t6i teo niém mac va di sin rudt, loan san va cuéi cling Li ung thu. Nhiém H_pylori lam ting nguy co UTDD len gap 6 lan. 2.3. Yéu té di truyén Uéc tinh UTDD co tinh chat gia dinh chiém ty 1é 1-15% trong UTDD. Mot sé bénh ly di truyén ciing tang nguy co. 2.4. Cite yéu té khiie Cac bénh ly tai da day cing lé nguyén nhin gay UTDD. Nhiém xa efing duoc coi la m6t yéu t6 lm tng nguy co mic UTDD. guoi bénh mic 3. Phan giai 3.1. Phin loai TNM thur da day (theo AJCC 8th)Tl ‘U nguyén phat ‘Unnguyén phat khong thé dang git duye Khong c¢ bing chimg cia u nguyén phat di trong lp biéu mo, logn sin mic 9 ca0 U xii lin lp df, co nitm hofe didi niém Tia: U xam Lin lop 4m hodc co nim Tb: U xd Kin Lop dedi nim T2: Th: TA: Ta: U xii dn Kop co U xm kn lop dui thanh mae U xm lan thanh mac hod cfu tric lin cn ‘U xim lénthanh mac (phic mac tang) ‘Tab: U xim ln ea trac Iain ein DO bigt hos Gx: Gl: G2: G3: Khong danh gid duoc dé biét hoa Biét hoa t Biét hoa trung binh Bigt hoa kém, khong biét hod 3.2. Xép giai doan * Ghi chu: Giai doan ung thu da day theo lam sang (cTNM) Nx: Khong danh gia éuge di can nach NO: Khdng di ein hach ving Ni: Died 1-2 hach ving N2 icin 3-6 hach ving N3: ican ti 7 hach viing tr én 3a: Dicdin tr 7-15 hgch ving, 3b: cin tr 16 hack ving tr Hen M Khong di cdn xa MI: Cédicin xahu benh (pTNM): II. CHAN DOAN Ap dung theo khuyén cao cita NCCN 2-202, tuy nhién, khi ap dung tai BV Nguyén Tri Phuong ching (0i tudn theo cdc nguyén tic co ban va phii hop trong diéu kign hign 6 ctia bénh vin ciing nhu y té khu vuc, trén nguyén tac cé loi nhdt cho ngudi bénh xét ca trén yéu t6 chuyén mén lan chi phi. - Hoi bénh sit vi Kham lam sang - Tim sodt tién sir gia dinh - Noi soida day-té trang, sinh thiét va lam gi - Siéu am bung - CT scan ngue bung chu cé can quang dicing fink mach voi lam ching da day - PET scan khi nghi ngé di citn - Her? vi MSI/MMR, PD-LI khi di cin hoje nghi nga di cin - Xem xét gidi trinh we gen (NGS may be considered) - Tw van di truyén, diéu tri dich, theo d6i tén die ung the... d6i v6i cée treéng hop cin thiér - Dénh gid phan logi Siewert (néu u 6 ESJ) - Siéu 4m qua néi soi (chura 4p dung) - Endoscopic Resection (chua ép dung) - _ Sinh thiet di can (néu c6 va tuy trong hop) - Xétnghigm sink hod, huyét hoe - Déinh gid va can thigp dinh duwdng - Dénh gid tong trang theo ECOG - Dinh gid chite nang céc co quan, cic bénh di kem va t6i wu hod tridie mo - Ap dung ERAS shdu bénh IV. DIEU TRI Dicu tri ung thw da day 1a diéu tri da mé thite bao gém can thiép qua néi soi, phau thuét, hoa tri, xa ti, ligu phap nham twang dich, mién dich... Tuy theo tig giai doan, tuy ban chat ung thu, tinhtrang ngudi bénh, ngudn luc cla nganh y té ma ching ta 6 chién Iurgc diéu tri phd hop nhét cho timg ngwéi bénh. Du thé nao di nita, loi ich cho > ng ud ‘bénh 1a wu tién 1g du xét trén ca khia canh chuyén méa lin chi phi cting nhu st tién loi nhat cho ngudi bénh. Cin eft vio nguyén tic nay, chiing 101 dua ra phic do diéu tri ung thu da day phii hop nhat c6 thé trong diéu kign hign nay (2023). 1. Phiu thuat PHAU THUAT TRIET CAN Ciit da day tiéu chudn: nhim muc tiéu triét cn v6i cit it nhat 2/3 da diy kém nao hach D2 Cait da day khéng tiéu chudn: cling v6i muc dich trigt cin nhung mite d6 cat da day va mite d6 nao hach thay d6i tuy theo giai doan ung thu, bao gsm: Phéu thu@t cai bién: mirc 46 cit da day va nao hach thip hon so véi cit da diy tigu chuin (D1, DI+) Phéu thudt mé réng: da day kém cée co quan khée; ct da day kém nao hach hon mite D2 PHAU THUAT KHONG TRIET CAN Phau thuat khéng cin mue dich triét cn, tuy theo muc dich ciia phdu thudt mi cé thé chia Phau thuit giam nhe (Palliative surgery) va phiu thuat giam khéi (Reduction surgery). ii niém phdu thudt lam sack! Phiu thudt gidm nhg: nhim giai quyét cdc bién ching nhu x phiu thudt cé thé lua chon bao gém cat da diy, ndi vi trang hoc phi da day (Stomach-partitioning gastrojejunostomy) tuy theo tinh trang khéi u va tinh trang ngudsi bénh. Phéu thudt gidm Khoi phau thuat cat bo nhim lay bo u nguyén phat, ngan ngtra cae bien chimg (chua xdy ra) di khong dat duoc muc tiéu trigt dé (da di can, R2....). Hign khong duge khuyén cao vi Khéng ching minh dure loi ich. CAC MUC BO CAT DA DAY Theo quan diém cia Nhit Ban Cit toan b§ da de toin bd da day bao gdm tam vi va mén vi Ciit phn xa da day: cit phin xa da day bao gsm mén vi, bao t6n tim vi. Trong cit da day tigu chun, 2/3 da day duge cit b6 Ciit da day bao ton mén vj (PPG: Pylorus-preserving gastrectomy): cit da day bio tén 1/3 trén ciia da day va mén vi cing véi mét phan hang vi Cit phan trén da day (PG: Proximal gastrectomy): cit da diy bao gém tam vi, bao ton mon Kl huyét, hep mén vi. Cie thuit ndi vi tring phn tich Ciit dogn da diy (Segmental gastrectomy): cit mét khoanh toan cho vi da day, bao tn tam vi va mon vi Cit da day khu tri (Local resection): resection?) Non-resectional surgery Completion gastrectomy: cit toan b6 phan cin lai cia da diy Subtotal resection of remnant stomach: cit phan xa phin cin lai ciia da day M6t s6 khai nigm khic: Cit gin toin b6 da diy (Near-total gastrectomy) Ciit 95% da day (95% gastrectomy) Subtotal gastrectomy with very small remnant stomach XAC DINH MUC DO CAT D4 DAY Bo efit: Bé cit gin (dign cit trén) it nhdt 2em déi véi uT1, 3em véi uT2 (thém chi u xém Hn su hon) déi véi u type 1,2. Véi cic u dang thim nhiém (type 3.4) thi bé cat can it nhat Sem. Khi khong dat cdc tiéu chi nay thi can thy hign sinh thiét tie thi. MUC DO NAO HACH cit mot phin da day khong lay hét chu vi. (Wedgeon on ace wow como wn D> Di: ngohgch thom 01 ‘DO:nao hach ithon D1. cit toan v9 .. JO Diimoctentsn 7. cétphana JO BENT TS putin aati Die bi-taa aay D2: D1 + Ba, 9, 11p, 11d, 12a soci ~— ‘D2:D1 + Ba, 9, 11p, 12a. Dingo ach then DL Dictate ub? D0 mosh thon Distbiedesttip. feapeay | 7 pn aia kanal Debora cinisa Sotinming NF pilot 2, Hoa tri Thudc ho - SFU: 5-fluorouracil Tegafur/Gimeracil (CDHP: §-chloro-2,4-dihydroxypyridine)Oteracil - Levofolinate calcium - Capecitabine (Xeloda) - Cisplatin (CDDP: cis-diamminedichloroplatium) - Oxaliplatin = Irinotecan - Docetaxel - Paclitaxel - Nab-paclitaxel (Abraxane) Phéi hop: - Xelox, Capelox: Capecitabine/Xeloda + Oxaliplatin - FOLFOX (FOLinic acid/Fluorouracil/Oxaliplatin): Levofolinate calcium + 5- fluorouracil + Oxaliplatin - FOLFIRI (FOLinic acid/Fluorouracil/Irinotecan): kh6ng ding cho ung thu da dy Ung thir da day giai dogn II, TI Hoa ti hd to Muc tiéu: = Diét cdc t8 bao ung thu cén sét lai.- Giam nguy co tai phat, cai thin thoi gian song them. Chi dinh: - Nguoi bénh ung thur da day giai doan I-IIL, duoc PT trigt edn vét hach D2, dign cit Khéng con té bio UT. Phéc dé khuyén edo: CapeOx; FoiFox; hoge TS-1 & ngudsi bénh chau A. Hoa tri tin hd troy Muc tiéu - Gidm giai doan (kich thud va su xm lin ciia u, giim di cn hach), ting kha nang PT trigt cin RO. - Gidm vi di cin truée PT, gidm ti 1é tdi phat tai chd va di cin xa, cai thign thi gian séng thém toan bé. - Danh gid duoc dé nhay véi héa chat. Chi dink, - Nhitng trudng hop UTDD tién trién tai chd cén kha ning PT (cT2 tré len; bat ki N theo NCCN)! hod hach bulky (theo ICCA). Phéc do khuyén cdo: FLOT; Folfox; hod S1-Cisplatin. Ung thu da day giai doan TV Mue tiéu ~ Didu tri trigu chimg, cai thign chat long c ig cho ngudsi bérih. - Kéo dai thai gian sng thém khéng tién trién, thai gian sng toan bd. Diéu tri bude |. Her2 (-): Phac dé khuyén cdo: S1 — Cisplatin; Capecitabine — Cisplatin; SFU/Cisplatin; CapeOx: $1 — Oxaliplatin. Her2(+); Pha dé khuyén cdo: CapeOx — Trastuzumab; SOX — Trastuzumab Diéu tri bude 2 Her2 (-) Phac dé khuyén céo: Paclitaxel; Nab-Paclitaxel; Docetaxel; Irinotecan + Ramucirumab Her2 (+) Phéi hop thém Trastuzumab néu chura duge str dung trirée dé. MSI-H Pembrolizumab néu trudc dé chua duoc xai ite ché diém mién dich. Dieu tri bude 3 va sau dé. Irinotecan hoje FTD/TPI . Nivolumab néu tude 46 chua xai tte ché diém mién dich. 3. Nhim tring dich - Bevacizumab (Avastin): la khang thé nhan tao (IgG1), tac dung khang sinh mach. Khéng cé chi dinh cho ung thu da day - Trastuzumab (Herceptin): Khang thé don dong, chi dinh khi Her2 (+) - Ramucirumab (Cyramza): li mot khéng thé don déng tai t5 hop, tc ché thy thé yeu 16 ting truéng ndi m6 mach miu 2 (VEGFR2) - Pembrolizumab = Nivolumab 4. Xa - Xa tri don thudn chi yéu diéu tr trigu chimg nhw hep mén vi, - Héa xa tri déng thai con duge chi dinh cho céc UTDD tai ché khong cat bo duge hoac thé trang ngudi bénh khéng cho phép phau thuat. Khi d6, mue dich diéu tri eé thé ld trigt cin hay tam thi tiy theo timg tinh huéng lim sang.- Hoa xa tri bé tro sau phiu thuat trong trong hop dién cat sau phiu thuat con té bao u trén vi the (RI) hode trén dai thé (R2), Nhiing ngudi bénh duoc ciit da day khéng tridt dé hay 06 dign edit durong tinh ciing c6 thé duce diéu tri phéi hop da mé thite sau mé mét cach phii hop. ~ Xa tri trong digu tri di cn xuong va nao. 5. Luu dé xir tri Cenatane Cornu no) eane [are] Less azrn] [Peseta ][Ce.rie ) omer enuecst |" “ab Bully Re yu tug the iba ret de? Phoihop ne Serer sola rns aa cttén haan No Yet lta ann | —caeap és ey 0 itu gm peor || enone | Onsen perio) Ghi chi: = CYI: té bao ung thie trong xoang phic mac duong tinh khi lam cell-block (positive lavage cytology) - Pla: not di cin khu tri xoang phic mac (localized peritoneal metastasis) - LECS: (Laparoscopic endoscopic cooperative surgery) idu tri sau mé cit da day: - Ung thu giai doan I: theo déi dinh ky Ung thir giai doan IT, ITT: hod tri hd tro - Ung thi giai doan IV: digu tri giam nhe, nang d6 + hod tri triéu chtmg 6. Ung thu ving néi thye quan — dg day (EGJ: Esophagogastrie junction) khéc nhau trong dinh nghia ving néi gitra thye quan va da day. Theo quan diém ca Nhat Ban, ving néi la ving nim trong pham vi tren duéi 2cm tinh wr dong Z, trong khi dé theo AJC 8 thi Hg thang phan loa_[ Phin loat Moti Phan loai Siewert Type I Doan tir Sem dén Iem trén EG Type II Doan tir lem trén EGJ én Jem duréi EGI Type Il Doan tir duéi EGJ 2em dén Sem Theo AICC8 Ung thu thue suse Tir duéi BGI 2em tro len Ung thu da Tir duéi EGJ 2cm tro xu6ng Phan loai Nhat Ban | Chia 5 loai oe) La ving trén dudi EGJ 2cem Phin logi Siewert (hign duge Ap dung rng rai, bao gdm et NCCN): = Siewert Type I: ung thir biéu m6 tuyén ca thc quan dui v6i tim khéi u vi Lem dén 5 cm phia trén EGJ. trong pham= Siewert Type II: ung thu biéu mé thue su cia tam vi v6i tam kh6i u nam trong pham vi 1 cm 6 trén va 2 cm 6 duéi EGJ. = Siewert Type III: ung thur biéu mé dudi tim vi voi tm khéi u nim duéi EGI tir 2 em dén 5 em, tham nhiém vao EGI va thu quan duéi tir bin dui. sem CChé n6ithycquin daday Phan biét phan loai Siewert (A) va phan loai Nishi (B) durgc cae tac gia Nhat Ban sir dung: equi | eos oe E EG E=G GE G *Ghi chi: Phan chia thc quan theo cic trudng phét Theo Nhat Ban Theo AJCC 8 Méc gidi han giai phiw Méc gidi han giai phiu Thye quin 3 (Ce) [16 thue quin dn homie | Upper | Ha hau dn hom ie Thye quan ngye (Te) | Hom ire dén bi trén ca khe hoanh thye quin = Thye — quan | Tirhom ite t6i Carina Upper _ | Hom de ti TM don ngye trén (Ut) (Azygos) - Thye quan | Nita trén cia doan thuc quin| Middle [Dui TM don ti ngye ——gidta | tir Carina dén EGJ TM phoi duéi (Mt)= Thye — quan | Phan tren nguc cua ntta dui [Lower Dudi TM phoi duci ngye duéi | cla doan thyc quan tir Carina t6i EGI (Lp) dén EGI (tir diém gitta doan ay dén bo trén cla khe hoanh thye quan) Thye quan byng (Ae) | Phan trong 6 bung cia ctia | Lower Tu EG! dén 2cm nita duéi ciia doan thye quan] EGJ/TAm | duéi dang nay tir Carina dén EGJ (tir bo trén | vi cia khe hoinh thuc quan dén EG) b. Luu dé xit tri U type I duge xir tri nhur ung thu ctia thuc quan con type III thi duge xir tri nhur ung thr da diy. Riéng type II thi ap dung theo liu dé sau: Siewert, cT2- eT Di cin hach ving trung théttrén vagida (hid di thye quin bid iin >4.0en 2.1-4.0m = 2.0om Neo hach cic ching 1,2, || Naohach cde ching Ngofach cieching 3a, 7, 8a, 9, 11p, 19, 1, 2, 30,7, 62, 1,2, 3a, 7, 106recR, 107, 108, 109, 110, 111, 112 9,11p, 19, 110 82,9, 11p, 19 Tiép cin tu ngve phai Tiép cin tirkhe hoanh v. CACH CHAM SOC sau phiu thudt (ERAS) VL. TIEN LUQNG BIEN CHUNG . Bang 8: Song thém 5 nam ciia ung thir DAT TRUC TRANG ‘Theo doi va tai khim: Na 1 2 3 4 5 Tha [3691 [1 | rae) a0 eo ao nal | Bal ea sing Siu am. sean 10Biéu db jch theo ddi va tai kham * Ghi cha: - Lam sing: héi bénh, khdm lim sang lién quan va cic XN méu - Noi soi: - Sigu am: - CT sean: - SINH THIET LONGNgiy ban hinh: . . . . / 2023 Sé trang: PHAC DO DIEU TRI UNG THU DAI TRUC TRANG Lan ban hinh; 1903 in soan Tham xét Phé duyét Hp vate _ TS.BS. ____ BS.CKIL. _ BS.CKIT ove ten LE HUY LUU Lé THAI BINH KHANG VO ptiC CHIEN Chiredanh | PAY nae Neos TP. Ké hoach tong hop Giém Dée Chit ky 1 MucTIEU: - Phac dé duge thiét lap nhim thong nbdt trong chén doan va digu tri ung thr dai truc trang, gop phan chuan héa va nang cao hiéu qua dicu tri. Ml. PHAM VI AP DUNG , Phac d6 ditoc ap dung cho t 1. TRACH NHIEM - im si thii quy trinh thuc hign xét nghiém, chan doin, - Diu dudng khoa lim sing chiu trich nhiém thyc hign y lénh. IV. TALLIEU THAM KHAO 1. BO Y té (2020). Ung thu dai truc trang. Huéng dan chan doan va Nha xuat ban Y hoc. 2 Phac do diéu tri ung thu dai true trang cua DHYD 2021. ‘4 bénh nhan duoc in dodn ung thu dai trac trang. tri theo phic 43. iéu tr} mot s6 bénh ung busu 3. Colon & Rectal cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up 2017 4, National Comprehensive Cancer Network (2020). Colon & Rectal Cancers. NCCN Clinical Practice Guideline in Oncology. 5.ISCCR 2019 v. TU wer TAT UTDD Ung thir da da AJCC Uy ban lien hop vé ung thu Hoa Ki EMR Cat bo niém mac qua néi soi ESD Cat bd dui niém qua ndi soi NCCN Mang Ludi ung thu quéc gia Hoa Ki HP Helicobacter Pylori NGS Giai tinh wy gen thé hé moi MSI Bat 6n dinh vi vé tinh MMR, Khiém khuyét siia chita bat cp sai MRF Mac treo true trangVL CRM Dién cat theo chu vi true tran; NOLDUNG I. DAI CUONG 1. Dich té Theo GLOBOCAN 2020, ung thu dai true ung thu vi va ung thu phéi, véi khong hai trigu ca mic méi trong nam 2020. Xuat d6 etia ung thu dai truc trang 14 23,4/100000 6 nam va 16,2/100000 6 nit. Tai Viet Nam, théng ké nim 2020 cho thay sé ca a, dig hing thir ndim trong s6 cae bénh IY ung thu. dic méi ung thu dai truc tring la 16450 2. Yéu té nguy co = Cac héi chimg di truyén: Hi chimg da polyp gia dinh, Hi chimg Lynch, Hi chimg Peutz- Jeghers - Viem rudt man tinh (viém loét dai true trang, bénh Crohn) ~ Théi quen sinh hoat: Hit thude 1a, uéng nrgu bia, 16i séng tinh tai, ché 46 an nhiéu thit d6 va thiic an dong hop Hi ching chuyén héa, dai thio dung, béo phi, 3. Phan chia dai true trang Bang 1: Phan chia dai 4, Phan giai doan ung thu dai true trang (theo AJCC 8th) 4.1. Phiin lo: ‘NM T Tx Khong ré u nguyén phat TO | Khon, cchimg u nguyén phat Tis | Ung thur tai ch, trong l6p niém mac (16i lip dém niém mgc, chua t6i lép co niém) T1__| Ung thur xm lan i lp duréi nigm T2___| Ung thi xm lin ti lop co 73 ‘Ung thu xam lin qua lép co, t6i lép thanh mac 14 T4a: Ung thu xm lan qua lép thanh ma Tab: Ung thu xam lin tric tiép hdc dinh cae eo quan hod cfu tric lan cn N Nx | Khéng danh gid duoc hach vin; NO__| Khéng di cin hach ving NI [Di cin 1-3 hach viing yy di can hach ving, nhung 6 té bao u 6 lép duéi thanh mac, mac treo dai trang hodc mac treo true tran N2__|Dicin 34 hach ving N2a: Di edn 4-6 hach N2b: Di cain > 7 hach MO | Khéng thay di cin xa trén hinh anh hoc MI__|Dican xa Mla: Di cn I co quan hoic vj tri ma khong cé di edn phiie mac MIb: Di cain 32 co quan hode vi tri ma khong ¢6 di can phic macMle: Co di cin phite mac D6 bigt ho’ GX: Khong danh gid duoc 46 biét hoa Gl: Bigt hoi tot G2: Biét hod trung binh G3: Biét hoa kém, khéng biét hod 4.2. Xép giai doan * Ghi chit Giai doan T N M 0 Ts NO MO. I Ti-12 NO MO. HA T3 NO MO IB T4a NO MO 1c T4b NO. Mo. TA T1-12 NINIe Mo. TI N2a MO. IIB T3—T4a NUNIc MO 12-73 N2a MO Ti-72 N26. Mo. MIC Téa N2a Mo. T3—T4a N2b MO. T4b NI-N2 MO IVA Bat ky T Bat ky N Mia IVB BitkyT MIb Ivc Bit ky T Bat ky N, Mle II. CHAN DOAN 1. Lim sing wu nhur khong c6 trigu chimg 6 giai doan sém Céc trigu chimg 6 giai doan tién trién thi cling mo hé, khong dic higu bao gdm trigu ching co nang nhu r6i loan di tiéu, tio bon hode tiéu chay, tiéu méu, dau bung, chan an, sut can... va trigu chimng thye thé nhur than phat hign thiéu miu, gay sit, so thay hach di 2. C§n lim sing qua thm hju mén true tring; kham todn Chan doan xac dinh: Ni soi dai truc trang, sinh thiét lam giai phau bénh “& Chan doan giai doan: © CT scan ngue - bung - chau ¢6 can quang © Déi véi ung thu truc tring, MRI chau cé hoe khéng c6 thudc twong phin tr ding dé danh gid giai doan T vi N. MRI cing gitp danh gia tinh trang mac treo true trang (MRF- mesorectal fascia), tir dé gidp tién doan dign cat theo chu vi true trang (CRM - Circuference resection margin). Siéu am qua néi soi néu cé diéu kign, chi dinh trong mét sé truimg hop X quang dai trang 6 can quang c6 thé cn trong mét sé trudng hop. Xa hinh xuong, PET scan khi can khao sat di can khac CEA; CA 19.9, phéi hop véi cic phuong phép khac dé theo dai va chin don ung thu tai phat, di cdin sau digu tri. “M6 bénh hoe: o. Ung thu dai trang duc phdu thuat trigt can, dnh gid giai doan m6 bénh hoc bao gém: 0000DO mo hoc Giai doan T Sé Iuong hach vét duroc va s6 hach dyong tinh Digan cit trén, dign cat dudi va dién cit xung quanh w Su xdm lin thin kinh mach miu ‘Su xam lan mach bach huyét Nhén ung thr mac treo ngoai hach Dah gid di cin hach Sé long hach vét duge téi thiéu 12 hach dé dim bao xép loai giai doan chinh xc. éi v6i benh nhan ung thw dai tring giai doan UI dé quyét dinh digu ti b6 tro 6 giai doan niy hay khéng can xét nghiém MSI (PCR) hoge MMR (phuong phip héa mé mién dich). Véi nhimg bénh nhan nay néu dMMR hodc MSI-H cé tién Iuong tot va khéng duoc hung loi khi hée tri bo tro v6i 5-FU. “© Xétnghiém gen: KRAS; NRAS; BRAF; MMR/ MSI néu can . “& Sinh hoe phan tir: Tu van di truyén, diéu tri dich, theo doi tén dur ung thu... di véi ede truding hop can thiét % Banh gid tinh trang ngudi bénh: chite nang gan, than, hé hap, tim mach, déng mau, dinh * one IL HUONG XU'TRI Chin hroc diéu tri cho bénh nhan ung thir dai true tring duoc vach ra bai di ngii bac st nhiéu chuyén khoa khic nhau, bao gém: bac si NGi soi, bac si chuyén khoa hod tri, bac si chuyén Khoa xg tri va phau thuat vién ung thy tiéu hod. Phéi hop digu tri da md thitc, ty giai doan ma cé thé thuc hién ct niém mac qua ndi soi, phiu thudt hod két hop ca hod tri, xa tri va phdu thuat. __Cé surkhac biét nhat dinh gidta quan diém cita phuong Tay va Nhat Ban, chiing t6i s€ edn nhic timg trudmg hop cu thé nhm dim bio loi ich cita nguéi bénh. IV. DIEU TRI A. PHAC DO DIEU TRI UNG THU DAI TRANG 2023 (NCCN 2020 — JSCCR 2019) 0000000000 Chong 1: Diéu tri ung thu dgi trang giai doan 0- giai dogn IIT 1. Can thigp qua ndi soi (tam thoi dp dung giéi han tai NTP) - Tén thuong it nguy co di cin hach lympho (polyp pTis hoc pT1 xm lan it lop dui niém). + Kich thud t6n thuong khéng anh huéng dén chi dinh, mién sao dam bio cit tin throng thanh mét mau nguyén ven. - Dang tén thuong (polyp phiing hod cé cudng) khéng anh huéng dén chi dinh. ~ 2em la dung kinh lén nhit dé thue hign ct polyp hode ct niém mac (EMR) bing thong long. Doi véi Ki thuat ESD, kh6ng c6 giéi han trén cho dudng kinh cia tén thuong. “& Cit polyp: snare duoc dit & chan tén thuong, tan throng diroc cit bing song din cao tin. Ki thuat nay duge sir dung cho cae tén throng chdi siti nhé vao long dai tring. & EMR: t6n thuong duoc nang Jén bang cach tiém nude mudi sinh ly vao lép dusi niém mac, én thuong duoc cat bang snare hoac bang cap (EMRC). Ki thuat nay ap dung cho cée ton thuong néng, tin thuong dang phing. % ESD: ton thuong duoc nang lén bing céch tiém Natri hyaluronate vio lip duéi niém 6 ving quanh t6n thurong, sau dé niém mac ving quanh tn thuong duroc cit bing dao chuyén dung,va tOn thyong duge cat thinh mét khi. Ki thuat nay ap dung cho céc ton thuong l6n, ung thu sém, khéng eit duge nguyén khéi bing EMR. - Theo di sau can thigp qua n6i soi céc ung thir pT1, can két hop néi soi, CT nguc bung chau, dau én ung thu. - Tai phat sau can thiép qua néi soi thutng xay ra trong vong 3 nim. © Méhoc thuan loi: - Grade I hoe 2 - Khéng xdm lin mach mau, mach lympho. - Dién cit khéng té bao ac tinh © Méhoc khéng thuan loi: - Grade 3 hoe 4 - Xam lin mach mu, mach lympho ~ Dign ciit khéng an toan + Té bao dc tinh hién dién 12 thing ‘ho§e héatrj phic 43 capecitabine hodeS-FUILV bobs chun tinge tei Da timghoatri Hoie Hoa‘ trigu chime trade diy: ‘© FOLFIRV/rinotecan+ Phic dé bbevacizumab (uu tién)iziv= oxaliplatin: theo aflipercept/ramuciramab daithém ‘© FOLFIRI/rinotecan+ Phic dé khés: hia ‘cetuximab’ panitumamab trjtriguching (chichodstbign KRASINRASBRAF WT) Chua ting hoa ti ‘+ Nivokumabsipiimamab trusediy: ‘+ Pembrolizamab (chicho FOLFOX hode ‘dMMR/MSI-H) CAPEOX (wu ‘+ Encorafeniy+cotuximabl tiga) ppanitumamab (chichod6t Capecitabine hoge bbign BRAF VoO0E) 5-FUfleucovorin Lucu dé 4: Xie bf ung thu dai trang tai phat ‘Mot sé phac do héa tri ung thir dai tree tring: - Phic dé FOLFOX4: + Oxaliplatin: 85 mg/m2, truyén tinh mach, ngay 1 + Leucovorin: 200 mg/m2, truyén tinh mach, ngiy 1, 2 +5 FU: 400 mg/m?, tiém tinh mach, ngay 1,2 + 5 FU: 600 mg/m2, truyén tinh mach trong 22 gid, ngay 1,2Nhic Iai sau méi 2 tuan. = Phac dé FOLFOX6: + Oxaliplatin: 100 mg/m2, truyén tinh mach, nga + Leucovorin: 200mg/m2, truyén tinh mach, ngay 1,2 + 5 FU: 400mg/m2, tiém tinh mach, ngay 1, 2 + 5 FU, 600 mg/m2, truyén tinh mach trong 22 gid, ngay 1,2 Nhe Izi sau mdi 2 tuan. - Phic dé mFOLFOX6: + Oxaliplatin: 85 mg/m2, truyén tinh mach, ngay 1 + Leucovorin: 350mg/m2, truyén tinh mach, ngay 1 + 5 FU: 400mg/m2, tiém tinh mach ngay 1, sau dé 5 FU: 2,4g/m2 truyén tinh mach trong 46 gidlién tuc. Nhic lai sau méi 2 tuan. = Phac d6 FOLFOX7 + Oxaliplatin: 130 mg/m2, truyén tinh mach, ngay 1 + Leucovorin: 400mg/m2. truyén tinh mach, ngay 1 +5 FU: 2,4g/m2, truyén tinh mach trong 46 gid lién tuc. Iai sau méi 2 tudn, + Trinotecan: 180 mg/ m2, truyén tinh mach, ngay 1 + Leucovorin: 200 mg/m2, truyén tinh mach, ngiy 1, 2 +5 FU: 400 mg/m2, tiém tinh mach cham, ngay 1,2 + 5 FU: 600 mg/m2, truyén tinh mach, ngay 1,2 Nhic Iai sau méi 2 tuan. -Phic dS FOLFOXIRE + Irinotecan: 165 mg/m2, truyén tinh mach, ngay 1 + Oxaliplatin: 85 mg/m2, truyén tinh mach, ngay 1 + Leucovorin 200 mg/m2, truyén tinh mech, ngay 1 +5 FU: 3200mg/m2, truyén tinh mach trong 48 gids Lap lai sau méi 02 tuan. - Phic dé XELOX: aliplatin: 130 mg/m2, truyén tinh mach, ngay 1 abine: 1000mg/m2 uéng, 2 lan/ngay x [4 ngay. Chu ky3 = Phie dé XELIRI: + Irinotecan: 240-250 mg/m2, truyén tinh mech trong 90 phit, ngay 1 + Capecitabine: 1000mg/m2 uéng, 2 lin/ngay x 14 ngay. Chu ky3 twin Hole + Irinotecan: 175 mg/m2, truyén finh mach trong 30 phiit, ngay 1 + Capecitabine: 1000mg/m2 uéng, 2 lin/ngay x 7 ngay. Chu ky2 . - Phac dé Capecitabine: Capecitabine: 1250mg/m2 udng, 2 lin/ngay x 14 ngay. Chu ky 3 ic d6 TS 1 don thuan: TS 1 60-80 mg/m2, uéng ngay 1-14, chu ky 3 tuin (21 ngay) hodc TS-1: 60-80 mg/m2, udng ngay | -28, chu ky 6 tuan (42 ngay). - Phac d6 UFT: UFT (Tegafur+Uracil): 100 mg /m2, uéng/lan x 3 lan/ngay, ngay 1-28 Folinic acid: 30 mg/m2, uéng/lan x 3 lan/ngay, ngay | -28 Chu ky 5 tun. . : UFT (Tegafur+Uracil): 100-125 mg /m2, uéng/li 21 ngay.= Phac 46 ILF: Trinotecan: 125 mg/ m2, truyén tinh mach ngay 1 Leucovorin: 20 mg/m2, truyén tinh mach ngay 1 5 FU: 500 mg/m2, truyén tinh mach ngay 1 Diing hing tun x 4 tuin, nghi 2 tuan sau dé nhac lai. - Pha dé Trinotecan don thuai Irinotecan: 350 mg/m2, truyén tinh mach trong 30 phiit, ngy 1. Chu ky 21 ngiy Hole Irinotecan: 125 mg/m2, truyén tinh mach trong 90 phiit, hang tuan, trong 4 tuan, chu ky 6 tuan. - Phée 6 Oxaliplatin don thuai Oxaliplatin: 130 mg/m2 truyén tinh mach trong 2 gid, ngay 1. Chu ky 21 ngay. - Phe d6 5 FU don thuan: 5 FU: 3500 mg/m2 truyén tinh mach trong 48 gig, hang tun (ngay 1, 8, 15, 22...). ~ Phée dé IRINOX: Irinotecan: 180 mg/m2, truyén tinh mach trong 90 phiit, ngay 1. Oxeliplatin: 85 mg/m? truyén tinh mach trong 2 gid, ngiy 1. Chu ky 14 n; Cac thude diéu tri dich trong ung thu dai tring - tre tring: - Bevacizumab: + Bevacizumab duge chi dinh cho ung thu dai true trang di cain hode diéu tri duy ti ung thu. dai tre trang di can sau khi dat n dinh bénl + Liéu diing théng thug 5-15 mg/kg, truyén tinh mach timg dot, phdi hop véi héa tri 14-21 ngay/lin. - Cetuximab: + Cetuximab chi dinh ding cho bénh nhén ung thu dai true trang di cin khong cé d6t bién KRAS, NRAS [RAS (-)]. + Liéu ding 400mg/m2 ngay 1 sau dé 250 mg/m2 hang tuan, truyén tinh mach hoi 500/m2, moi 2 tuan, phoi hop véi cac phac do héa tri. ~ Panitumumab: + Panitumumab duge chi dinh cho céc bénh nhan ung thu dai trac tring di cin khéng 6 dot bién gen KRAS, NRAS [RAS (-)]. + Liu ding: 6mg/kg, truyén tinh mach trong 60-90 phiit, mBi hai tun hode 2,5mg/kg, truyén dnh mach hang tuan, phéi hop véi cdc phic dé héa ti - Regorafenib: + Chi dinh sau khi bénh nhan da that bai véi phac dé fluoropyrimidin, Oxaliplatin, Irrinotecan, Bevacizumab hodc Cetuximab (RAS khéng dot bién) + Liéu ding: regorafenib 40mg x 4 vién ingay, udng mot lan/ngay, udng tir ngiy 1 -21, chu ky 28 ngay, cé thé diéu chinh liéu tity thuée bénh nhin. - Ziv-allibercept + Chi dinh Ziv-aflibercept trong diéu tri két hop véi héa tri phe d6 FOLFIRI cho bénh nhan ung thur dai tru trang di cin khang hoe da tién trién v6i cdc phic d6 c6 chita oxaliplatin. + Liéu long: 4mg/kg truyén tinh mach > 1 gids mdi 2 tun, - Ramucimumab: + Chi dinh trong UTDTT di cin da thit bai v6i héa tri c6 bevacizumab, oxaliplatin, flucrouracil. Ramucirumab chi dinh ding: phéi hop voi héa tri phic dé FOLFIRI. + Liéu long &mgikg truyén tinh mach > I giv mi 2 tuan. phac 43, 15Dieu tri mién dich: ~ Pembrolizumab 200 mg hode 2mg/kg truyén tinh mach >30 phiit mi 3 tuan cho dén khi bénh tién trién hod déc tinh kh6ng chap nhén duoc. - Nivolumab 240 mg hoc 3mg/kg truyén tinh mach > 60 phiit mdi 2 tuin cho dén khi bénh tién trién hoc déc tinh khdng chép nhan duge. TLTK s6 1 16B. PHAC DO DIEU TRI UNG THU’ TRUC TRANG 2023 (NCCN 2020 — JSCCR 2019 - ESMO 2017) Chuong 1: Diéu tri ung thu trye trang giai dogn 0- giai dogn IIL 1. Can thigp qua ngi soi (twong te dai trang) 2. Can thigp phau thuat ‘Ung thr try tring <12em sir mon * Khong di in xa Noi soi dst tye tring, sinh thi, wii pha bésh Xe nghin hayes hs, CEA. CT ngye bung chi MRI chju ab ttm thude twang phin tit Khing cls PETICT Xétnghigm mit dn din viv tn vst 185i bit fp (MMS) Tur vin chim sic, inh dia vit MINT tae mé Tu vin nguy oo tin i ki ning sinh sin TNO, <30% chu vi Sab T3cl'Thaly <3mm, Cir ua ab Hoa xg uta 88 uy Us thé ct due Uikhing thé cle doe pn] [ or>i Pia thie TME a tf iu ching sot | | sm on fo i vo,to | | vi,u1 apie | | apes q Theo 43) iba xa tb ty Luu dé 5: Xie bf ung the truc trang tién trién tai ving * Ung true trang >12em tir ria hdu mén durge digu tri nhu ung thu dai tring.* sm: xam lan lép du6i niém <1000 um , G: grade mé hoc, V: xam lan mach mau, L: xam lin mach lympho, BD: budding. (Hoa xa tri tan bd tro & nhtng bénh nhin dirgc danh gid c6 di can hach (N+) dua vao MRI con gay nhiéu tranh cai do: - Dinh gid di can hach don thuan dura vao kich thuée hach kém chinh xé - Tién long tai phat tai ¢ lua vao di cin hach trén MRI khéng dang tin cdy. ~ Tile tdi phat tai ché thap néu phdu thuat vién dam bio duce chat luong TME tit va phau tich mac treo true tring en bloc. O Phan gici doan ung thu true tring T3 ‘DO sau ung thu xam lan xuong lop co truc trang (mm) anh gia bang MRI trudc khi tién hanh diéu tri T3a 15 1 Danh gid chit Ivong phiu tich mac treo trc tring trong ph4u thuat TME ‘Chat luong Tat Mac treo truc tring nguyén ven, bé mit tron ling hode khiém khuyét nho, khong khiém khuyét nao sau hon Smm, mac treo hinh tru, CRM ra Trung binh Mac treo truc trang 6 khiém khuyét trung binh, chua 16 co truc tring, mac treo hinh nén, CRM khing ro Kém Mac treo truc trang khiém khuyét 16 dén lép co te trang, khong danb gié duge CRM Nguyén tic phiu thuat: Nao hach: * Can phi khao sat duoc téi thiéu 12 hach lympho duge dé dinh gid giai doan N. Hach nghi ngé di cin ngoai ving nao hach cin dugc sinh thiét hose nao néu 6 thé. Néu cén hach nghi ngé di can khéng nao duoc thi xem nhur phau thuat R2. Nao hach dura vio dong mach nuéi u, cic chin hach D1, D2, D3 duoc quy wée theo “Phan loai ung thy biéu mé dai trac tring, ruét thira va éng hau mén Nhat Ban” © Chidinh ngo hach theo timg chan duoc danh gia dya vao mite dé di can hach va mite a6 xam lin ctia u.© Ung thu gidi han trong lp niém mac (pTis) thi khéng cin nao hach vi ung thu pTis khéng di cin hach lympho. Tuy nhién, néu cé chi dinh eat doan truc tring (pTis trén nén polyp lon khéng cat dire qua ndi soi), ¢6 thé tién hanh nao hach D1 khi cat doan dogn true trang. * Nao hach D2 li can thiét cho ung thu cT1, tilé di cin hach lympho etia ung thu pT1 1d 10% va ti 18 di cin nhém hech trung gian li 2% © Ung thi cT2 cé thé tién hinh nao hach D2 hoac D3, ti Ié di cin nhém hach chinh 6 géc mach mau cia ung thu pT2 i khong 1%. © Ung thir cT3 tri lén hoe eN(+) c6 chi dinh nao hach D3. © Déi véiu giai doan 0-3, dién edt xa trén thanh true tring duéi u tir 3em tré lén ddi voi u nim trén nép phic mac va tir 2em tré Ién ddi v6i u nim dudi nép phiie mac la du vi té bao ung thu hiém khi hign dign vuot hon khoing cach nay. © Luu ¥, déi véi u pT4N2MI (giai doan 4) hodc u biét hoa kém, té bao ung thu c6 thé hign dign xa hon khoang cach nay. DiPhiu thuat xam ln ti thigu (phdu thuat ndi soi) durge chi dinh dua trén nhiing tiéu chi: Bac si phdu thuat cé kinh nghiém phiu thuat ndi soi cit truc trang. Phai dam bio tham sit duoc toin bd khoang bung. Thudng khing chi dinh trong trudmg hop tic rudt hoe v6 u. Nén danh dau cdc sang thuong truéc phau thuat. © Dam bio RO 6 dign cét xa va dign ct vong quanh. © Dam bio chite nang co thit. Luén bio tén than kinh ty déng tri trréng hop cd xém lin dai thé vao than kinh. Chi cn bao t6n mét bén cita dim rdi than kinh dé dim bao chite nang tiéu tién, Tuy nhi dé dam bao chite nang sinh duc nam, cu thé la chite ning xuat tinh, can bao tén hai bén cia dim ri than kinh. © Diibao tén hoan toan dam r6i than kinh, chite nang tiéu tién va chite nang sinh due nam vin cé thé bi anh huéng. © Bo dudi u nim dudi nép phic mac. e UT3 tro len 19Chwong 2: Diéu tri ung thu true trang giai dogn IV ‘Ss sng, dink hd itp engi hoi bo CEA (CTogue buns ee Rpm nb nang dict pn he om) DPETICT a thn dc ate ae) engi mt dink mW Bp ONIN) ‘gh dt ges RAS VABRA, hg hh dn HER2 ‘Wich amd tc Ou wn le Tc iahaei pa lt om mit vip. Phish de une pin wc in sei ha Luu d6 6: Xie bi ung thu truc tring tién xa di can Nguyén tic phiu thuat cit cdc tn thuong di cin: Gan: © Phau thuat la lua chon wu tién cho cac tn thong di can gan cé thé cit bo, véi diéu kién u nguyén phat 6 truc trang va céc u di cin khae phi duge cat trigt dé (RO). © Phai dim bao cit dugc hét tn thuong di can gan, déng thoi bao tén chit nang phin gan cén lai, © Néu phan gan con lai khéng di, c6 thé xem xét thuyén tic tinh mach ctta (TAE) hod edt gan hai thi (ALPPS) dé lim ting sinh phin gan cdn lai. Détu bang séng cao tin (RFA) co thé thay thé hodc phéi hop phau thuit cit cae tén throng. di cin gan. © C6 thé thu hién phiu thuit cit tric trang va clit cdc tén thuong di cn gan trong mét thi hod hai thi.Phoi: U nguyén phat 6 tne trang va cdc u di cain khac phai durge cit triét dé (RO). Phai dam bao ct durgc hét ton thuong di cin phdi, ding thoi bao tén chire nang phan phéi con lai. Dét u bing séng cao tan cé thé thay thé hoe phéi hop phau thuit cit cdc tin thuong di clin phéi. Cé thé thu hign phau thuat hod hai thi. At tre trang va ic ton thuong di cn phéi trong mét thi Dinh gid lai dé phiu thuat triét cn cho cfc tn thuong di cin khdng thé eft bo Khi danh gia giai doan gidi phu bénh phai danh gia duge cac yéu to Neudi bénh cin duoe dnh gid lai dé phdu thudt trigt c’n mdi 2 thang sau Khi tién hanh héa ti nhiing ton thurong di cin khOng thé ct bo duge trude di Khi dinh gid lei cdc tén throng di cn, u nguyén phat 6 truc tring cling can duge danh gid lai. Grade mé hoe cita ung thu D6 sau xm lan ciia khéi u (T) ‘So hach hao sat duoc va ach duong tinh (N) . Dién cit gin, dign cit xa, dién edt vang quanh, dién cit mac treo X4m lin mach lympho Xam lan thin kinh (PND) Cac tn thuong gieo ric 21Chwong 3: Ditu trj ung thu tryc trang tai phat [Nahi nad ung hur tye tring ti pit CEA miu ting #NGi soi ai tye tring, sinh thi, gi Khdng phithign tb thaong phi bah © Lip IsiCT ngye bung chau mdi 3 thing. © CT ngue bung chiu © PET/CT (néu CT va nji soi khéng phit ‘niga tn thuong) ‘Phiu thadt cit u FOLFOX/ CAPEOX tn ey 23 tong, vg 12 tg: thing + he 8 + FOLFIRVirinotee ‘n+ bevacizimd (om tenyav- afibacept ‘amucima ‘+ FOLFIRVirinotec an + cetuximab) panitamurab (hi ‘cho d6t bién KRAS/NRAS/BRAF wn ‘© Nivolumabeipilin sumab ‘+ Pembrclimumab (hi cho aMMR/MSL) oa tj ph 8 i! Ch hat: + Hea tririgu chimg. Litu dé 7: Xie bt ung thee true trang tdi phat *IORT: xa tri trong phau thuatOi Nguyen tic diéu tri ung thu truc tring tai phat: v. CAC Mue tigu Néuu phai wu tién phdu thuat ctu tai phat Néuu WW di can 6 xem xét phiu thu: trong cai thién -ai thign tién hrong va chat rong cu 6 thé dat due RO, can phéi cho thay higu qua u tai phav/di cn tai gan vavhod n luong sng ca ngudi bénh. 1H CHAM SOC sau phiu thudt (ERAS) VL. TIEN LUQNG BIEN CHUNG Bang 8: Song thém 5 nam cia ung thy DAI TRUC TRANG Theo doi va tai kham: Na 1 2 3 4 5 m Tha 1 ft ft [2 ]2 [2 ]3]3 3 [4 ]4 [sje ng 1/4 }7 }o]3 |e |2 /8 J4 Jo sean ch theo doi va tai kham * Ghi chu: - Lim sang: héi bénh, khém lim sing lién quan va cic XN mau - Noi soi - Sigu am: - CT sean: - SINH THIET LONG 23Ngiy ban hinh: . oo _— nk J (2023 Sé trang: PHAC DO DIEU TI JNG THU BIEU MO TE BAO GAN (HCO) Lin ban bak: Bién soan Tham xét Phé duyét Ho va té _ TS.BS. ___ BS.CKIL. _ BS.CKI ove ten LE HUY LUU Lé THAI BINH KHANG VO ptiC CHIEN ; Phu trach khoa Ngo: i Chite danh a Tigu Héa Bt TP. Ké hoach téng hop Gidm Déc Chit ky I. MUCTIEU: = Phae do due thiét lap nhiim théng nhdt trong chin doin va diéu tri ung thu biéu mo té bao gan, gop phan chuin héa va ning cao higu qua diéu tri. I. PHAM VI AP DUNG Phic 46 duroc 4p dung cho tat ca bénh nhan duoc chan doan ung thu biéu mé té bao gan. I, TRACH NHIEM thd quy trinh thuc hién xét nghiém, chan doan, tri theo phac do. - Diu dudng khoa lim sing chiu trich nhiém thyc hign y lénh. Iv. TALLIEU THAM KHAO 1. Jordi Bruix, Morris Sherman (2011), "Management of hepatocellular carcinoma: An update". Hepatology, $3(3), 1020-1022. 2. Fomer, Alejandro, Reig, Maria, Bruix, Jordi (2018), Hepatocellular carcinoma, The Lancet, 391(10127), 1301-1314. 3. Omata, M., Cheng, A. L., Kokudo, N., Kudo, M., et al. (2017), Asia-Pacific clinical practice guidelines on the management of hepatocellular carcinoma: a 2017 update, Hepatol Int, 11(4),317- 370. 4, Sung, Hyuna, Ferlay, Jacques, Siegel, Rebecca L., Laversanne, Mathieu, Soerjomataram, Isabelle, Jemal, Ahmedin, Bray, Freddie (2021), Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries, CA: A Cancer Journal for Clinicians, 713), 209-249. 5. Gomaa A, Waked I. Management of advanced hepatocellular carcinoma: review of current and potential therapies. Hepatoma Res 2017;3:112-122. 6. Jun, Chung Hwan MDa; Yoon, Jae Hyun MDa; Cho, Eunae MDa; Shin, Sang Soo MDb; Cho, Sung Bum MDa; Kim, Hee Joon MDe; Park, Chang Hwan MDa; Kim, Hyun Soon MDa; Choi, Sung Kyu MDa; Rew, Jong Sun MDa; Barcelona clinic liver cancer-stage C hepatocellular carcinoma, April 2017 - Volume 96 - Issue 17. in dodn va diéu tri HCC clia By Dai hoc Y Duge 2021 in don va diéu tri ung thu bisu mé té bio gan clia BO Y 16 nim 2020, s6 Sé: 3129/QD-BYT vy. TU WiET TAT HCC Ung thu biéu mé té 0 ganHBV. Vigm gan siéu viB HCC Vigm gan siéu viC AEP. Anpha Fetoprotein TACE iit mach héa cht déng mach’ AASLD _| Higp hdinghién cir bénh gan Hoa KY BCLC Barcelona clinic liver cancer VI NOIDUNG I. DATCUONG 11. Dinh nghia = Ung thurté bao gan (Hepatocellular Carcinoma: HCC) li mot loai ung thur gan nguyén phat, do su ting sinh de tinh cia cdc té bao biéu mé gan (Hepatocyte). 1.2. Thudt ngi va tir viét tit - VGSV: — Viém gan siéu vi - HCC. Ung thu té bao gan (Hepatocellular carcinoma) - AASLD: — Hiép héi nghién citu bénh gan Hoa Ky (American association for the study of liver diseases) - BCLC: Barcelona clinic liver cancer 13. Yéu té nguy co” = Khoang 80% ung thir yao gan xuat hign trén nén gan vim man tinh va xo hoa. ~ Do dé din sé nguy co cao bi ung thu té bio gan la Viém gam B-C man tinh, xo gan (do viém gam siéu vi hay doruou). Nhiing yéu t6 nguy co it gp hon li nhiém déct6 Aflatoxin, Dioxin... - Dan sé nguy co rit cao: - D 14. = Theo thong ké cita Té chite Y té thé gidi, © Xo gando virus viém gan B © Xo gan do virus vigm gan C Jan sé nguy co cao’ © Viém gan B man o Viém gan C man co Xo gan khéng do virus viém gan B, C Dich té hoc vim 2020, di v6i Vigt Nam, day la loai ung thur 6 ty 1é moi mac va ty Ié tur vong cao nhat. Il. CHAN DOAN 24. 241 Chan doain xée dinh Lim sing 2.1.1.1 Tién edn: Can tim hiéu cae yeu to: - Tién cin VGSV B, C hay xo gan. - Da digu tri VGSV chua? Cé tai khim va tam soat ung thu dinh ky khong? - Uéng rugu: da kéo dai bao lau, mite 6, néng dé... = Truyén méu, tiém chich, phdu thuit tude day. = Gia dinh cé tién sir bi VGSV, xo gan, ung thir gan. 2.1.1.2 Bénh sir: Can tim hiéu cdc trigu chimg: 24.2 2. = Cac dau hiéu xo gan. - Ganto. - Khoi. C§in Him sing 2.1 Cae xét nghiém miu- Maker VGSV B,C. ~ Dinh lugng siéu vi B, C. - Céng thire mau (sé long tiéu cdu: quan trong trong danh gia mite xo gan). - Déng miu toan bo. - Sinh héa miu: Bilirubin toin phan, truc tiép, gidn tiép, SGOT, SGPT. Mign dich: AFP, AFP-L3, PIVKA II, CEA, CA 19-9. 2.2 Chiin dodin hinh anh - Siu dm bung. = Do dé dan hoi nhu mé gan. - Chup CT hay MRI cé bom thuée can quang hay can ti. - N@i soi da day dinh gid tinh mach thye quan dan (that dur phong néu tinh mach din tir do Tro 1én). = X-quang phéi. - CT ngue néu X-Quang phat hign 6 sang thuong la (nghi di c&n....). 24.3 Cée tiéu chudn chan doin xée dink 2.13.1 Hinh anh dién hinh cia ung thw té bao gan . ~ Chup CT hay MRI dong, ¢6 bom thuée can quang hay edn ti: Khéi u ting quang trén thi dng mach va thai thude 6 thi tinh mach cira hay thi muén. 2.1.3.2 Dau dn ung thu AFP - Higa nay AFP > 200ng/ml 1a gid tri mang tinh goi cao chan doan ung thur té bio gan 6 nhiing ngudi bénh cé viém gan man tinh hay xo gan, tuy nhién gid tri nay khong, mang ¥ nghia chan doin xc dinh. 2.13.3 Sinh thiét gan - Sinh thiét gan 1a bign php sau cing dé xéc dinh chin doan trong nhing trig hop ngudi bénh cé sang thuong trong nhu m6 gam (>1cm) nhung khong théa 2 tiéu chun chan doin trén. 2.1.4 Phéc dé chin doan khdi u gan - Theo Hip hoi nghién ciru bénh gan Hoa Ky 2018 (American association for the study of liver diseases: AASLD)2.2. 23. UGAN -—— 3vau>3em Child-Pugh A-B Tin trién | 1-2 | Xm Jan mach mau hode | C14 pugh AB di cin ngoai gan U bit ky s6 Iuong va kich D: Cudi 3-4 | ce. Child-Pugh C WL. DIEU TRI 3.1. Nguyén tic diéu tri 3.1.1 Didu tri trigt dé 3.1.1.1 Ghép gan - Khéng chi loai bé khéi u khdi co thé ma cén thay thé gan da xo héa mi binh thuing, Day 1a phuong phap diéu tri tigt dé ti wu véi ty 1é Khoi bénh cao (50 - 70% séng 5 nim) va tdi phat thap (15% sau 5 niim theo dai). - Chi dinh ciia ghép gan. = Cie tigu chuan chon ngudi bénh ghép gan Tiéu chudn chi dinh cia Milan Tiéu chudn chi dinh cia UCSF Motu didi Sem Motu didi 6.5 em Nhiéu uw Nhiguu Du6i hoic bing 3 u Dui hodc bing 3 u Dudng kinh Ién nhat duéi 3em U lén nhat duéi4.Sem Téng dudng kinh duéi Sem Khéng xm lan mach miu hoe di cin | Khéng x4m lin mach mau hoje di cin ngoai gan. ngoai gan. 3.1.1.2 Phau thuat cit gan - Diy la phutong phap diéu tri trigt dé cho nhiing ngudi bénh cé thé trang cho phép, chife nang gan khong qua kém va khdi u con kha nang cat bd. ~ Kha ning khoi bénh 50 - 70% sau 5 nim theo di. Tai phét 70% sau 5 nim. 3.1.1.3 Hily u gan tai chi - Bay Ja phuong phap diéu tri tigt dé cho nhiing ngwai bénh ¢é khéi unhé hon 3em va sé luong u khong qué 3. - Vitrikhdi u dé tigp cin bing siéu am hay CT-Scan, khéng gan cdc tang khic, khong, gin cic cudng gan hay mach mau lén. . - Doi khi duoc chi dinh cho cdc khéi u nhé hon Scm nhung khéng thé diéu tri phau thuat (c6 thé ket hop TACE va RFA). im nhe 3.2.1.1 TACE: Duc chi dinh cho cic tring hop ung thu té bao gan: - Qué chi dinh can thiép triét dé. - Chuacé dicin xa, - Chua cé dau higu xm ln mach mau (huyét khéi tinh mach cita hay tinh mach gan).. - Chite nding gan Child A hay B. 3.2.1.2 TAE: Duoe chi dinh cho cae trubng hop ung thu té bao gan: - Dass6 cho cac truéng hop ung thu té bao gan vd, gay xuat huyét trong xoang bung.- Hay cae trudng hop cé chi dinh TACE nhung chife nang gan qua kém. 3.2.1.3 Ligu phép ton than: Duroc chi dinh cho céc truéng hop ung thu té bio gan: - Dicédicinxa, ~ Bi cé dau higu xém ln mach mau ln (tinh mach gan, tinh mach cita nhinh chinh inh phai-trai nhung khong thé lay be triét dé bing phdu thuat). - Chi s6 thé trang PST 0-2. ti dich va diu ti mién dich - Sorafenib li thuée tie ché da kinase durong uéng, duge coi la diéu tri bude mét chun cho cic teuéng hop UTBMTBG khéng céa dip ting hoaic khéng phi hgp véi cae bien phap dicu tri can thiép tai ché tai ving nhur nit mach héa chat, hode da c6 xdm nhap mach mau dai thé hay di edn ngodi gan, v6i diéu kign chite ning gan cdn tot (Child-Pugh A hay B7). Cic tic dung cia sorafenib ¢6 thé gap nhu: phan tmg da ban tay-ban chan, tiéu chiy, ting huyét ap... Cic tac dung phu nay thurong xay ra sém va cé thé dur phéng va kiém soat duoc véi céc bién phap ding thudc va khong ding thuéc. Liéu ding sorafenib 14 400mg, liéu sorafenib cho phi hgp theo mite d6 ca déc tinh. Nén duy tri viée sir dung sorafenib cho bénh nhan it nhat cho téi khi bénh tién trién trén hinh anh hoe, hoi trén lim sing, khi dé nén héi chan dé xem xét chuyén sang dieu tri buée hai. ing 2 lin’ngay cho t6i khi bénh tién trién. Cé thé diéu chinh ~ Lenvatinib 1a thuéc tte ché da kinase dung uéng. Lenvatinib cho két qua vé thdi gian séng cén Khong kem hon sorafenib va co thai gian sng khong bénh tién trién, thei gian cho dén khi benh tien trién va ty 1é dap tmg chung uu thé hon sorafenib trong ede nghién etru trén ede bénh nin UTBMTBG tién trién, khéng con dap tmg déi véi di cin ngoai gan, nhung chwa cé huyét Khoi nhinh chinh tinh mach . Lenvatinib duge sit dung didu tri bude mot cho cée bénh nhin thude nhém trén. Ligu ding lenvatinib la 12mgingiy & bénh nhan trén 60kg hode 8mg/ngiy 6 bénh nhan dudi 60kg, uéng hang ngay. Cie tic dung phu ciia lenvatinib fing twrong tr sorafenib. ~ Regorafenib, mét thude ife ché da kinase dudng udng, gittp cai thign ti1é singe c6n 6 cde bénh nhin UTBMTBG da diéu tri bing sorafenib, dung nap duc sorafenib, nhumg bénh van tién trién. Cic tic dung phu cia regorafenib ciing tuong ty sorafenib. Do d6, regorafenib duoc chap thudn nhu li diéu tri bude hai cho UTBMTBG khi da thit bai véi sorafenib. Liéu ding regorafenib: 160mg/ngay, uéng ngay 1-21, chu ky 28 ngay. rc ché chét kiém soat mién dich (immune checkpoints inhibitors) cho thay c6 thé cai thién ti 1é song con 6 cc bénh nhan UTBMTBG da dieu tri bang sorafenib hoac lenvatinib, va 43 duoc chip thuan diéu tri buée hai cho UTBMTBG khi da that bai véi sorafenib hodc lenvatinib. Céc tée dung phu chi yéu 1a mét méi, ngtra va phat ban. Liéu dung pembrolizumab: 200mg, truyén tinh mach chu ky 3 tuan - Mot sé nghién citu cho thay viée két hop bevacizumab véi atezolizumab cho higu qua trong viée cai thign thoi gian sng thém khdng bénh 6 cae bénh nhin UTBMTBG giai doan mudn hoi tii phat. Liéu ding: ¢ Atezolizumab: 1200mg truyén tinh mach ngay 1 * Bevacizumab: 15mg/kg truyén tinh mach ngay 1, chu ky 21 ngay - Ramucirumab 1a khang thé khang VEGFR cé higu qua diéu tri ung thir gan cd AFP > 400 ng/ml. - Cabozantinib 1a mét thuéc tre ché MET, VEGFR2, AXL va RET, ciing gitp cai thign ti lé séng con 6 céc bénh nhan UTBMTBG da diéu tri bing sorafenib.b, Héa tri toan than: mot sé phae dé héa chat c6 thé ap dung trong UTBMTBG nhung higu qui rat han ché. ~ Phac d6 PIAF: chu ky 3 tuan * Doxorubicin: 40mg/m2, truyén tinh mach ngay 1 * Cisplatin: 20mg/m2, truyén tinh mach ngay 1, 2, 3,4 ¢ 5-FU: 400mg/m2, truyén tinh mach ngiy 1, 2,3, 4 «Interferon a-2a: tiém duéi da 5 MIU/m2, ngay 1, 2, 3,4 ~ Phac dd GEMOX: chu ky 2 tuan * Gemcitabine: 1.000mg/m2, truyén tinh mach ngay 1 ‘* Oxaliplatin: 100mg/m2, truyén tinh mach ngay 2 - Phac 46 FOLFOX 4: chu ky 2 tuan * Folinic acid: 200mg/m2, truyén tinh mach ngay 1 © Oxaliplatin 85mg/m?, truyén tinh mach ngay 1 ‘© 5-FU: 400mg/m2, tiém/truyén tinh mach bolus ngay 1 ¢ 5-FU: 1.200mg/m2, truyé 3.2. Diéu tri cu thé - C6 rat nhiéu phac 46 diéu tri ung thu té bao gan trén thé gidi tly theo diéu kién Y té dia phuong, dic tinh cia ung thu té bao gan... - Ching t6i nhan thiy phac dé diéu tri ung thw té bio gan ciia Chau A, duroe nhiéu mide trong khu vue str dung va phii hop véi tinh hinh thy té tai Vigt Nam. ~ anh gia chire ning gan va dim bao dii thé tich bio t6n sau m6 li vin dé quan trong finh mach ngay 1, 2 toan bé trung vi 6.5 - 10.7 thing (Gomaa va cong su 2017). - Ung thwr té bao gan cé huyét khoi tinh mach cita khOng thé phiu thudt: thoi gian séng thém toan bé tung vi 2 - 4 thing (Jun, Chung Hwan va céng su 2017).Di cn ngoai gan Child - Pugh Cé thé efit gan Xam lin mach mau dai thé S6 long u Kich thuée u Hay u tai chd (3u,53 cm) GG Phuong phip diéu tri chudn. (CL Piste hip digu tri duoc fp dung rong rai 6 ving chau =, A - Thai Binh Duon; IV. THEN LUONG " e Lin dé 2: Phic dé diéu tri ung the té bao gan theo APASL 2016 SL. Theo doi ‘Sau khi diéu tri ung thw té bao gan, ngu6i bénh can tudn thu: diéu tri viem gan siéu vi va tai kham dinh ky dé tam soat tai phat. = Newii bénh can diac theo dai sau lan diéu tri dau tién 1 thang, sau dé cdich mai 2 thing dé phat hign sém va xit tri tai phat néu 06. + Méi lin tai khim, ngudi bénh cin duoc xét nghigm chite ning gan, men gan SGOT SGPT, AFP miu, néng dé siéu vi tong mau (néu cn) va siéu 4m tam soat tai phat. CT- Scan va MRI dtroc chi dinh khi sigu 4m nghi ngé cé tai phat trong gan.5.2. Phong bénh Tigm phéng vic xin khang siéu vi B cho tré em vita sinh ra déi. Tiém phong vie xin khang siéu vi cho ngudi lin chura c6 dui khang thé bio vé. > Tuyén truyén gio due cong dong phing ngita liy lan HBV vi HCV (quan hé tinh due tir me sang con). i ngudsi bénh vim gan B va C hoat don - Déi véi nhiing ngvai bénh viém gam B va C man tinh, xo gan, can tim soat dinh ky dé phat hign ung thir sém,Ngiy ban hinh: / (2023 S6 trang: PHAC DO DIEU TRI UNG THU TUY Lan ban hanh 1903 Bién soan Tham xét Phé duyét Ho va té _ TS.BS. ___ BS.CKIL. _ BS.CKI ove ten LE HUY LUU Lé THAI BINH KHANG VO ptiC CHIEN ; Phu trach khoa Ngo: i Chite danh a Tigu Héa Bt TP. Ké hoach téng hop Gidm Déc Chit ky 1 MucTiEU; , - Phie do duce thiét lap nhiim théng nat trong chan doin va digu tri ung thu tuy, g6p phan chuan hoa va nding cao higu qua dicu tri. M1. PHAM VI AP DUNG Phic d6 duroc 4p dung cho tat ca bénh nhan duoc chan dodn ung thu tuy. I, TRACH NHIEM im sing tuan thi quy trinh thuc hign xét nghiém, chan doan, diéu tri theo phic d3. - Digu dudng khoa lim sing chiu tréch nhiém thyc hign y lénh. Iv. TALLIEU THAM KHAO 1. NCCN 2023 2. ACCS 3. TU VIET TAT EUS Siéu am qua nGi soi da da 4 tran ERCP Oi soi mat tuy nguoc dong 4. NOIDUNG 1. DAICUONG Phac dé nay dp dung 6 nhiing tring hop nghi ngé hodc da xac dinh ung thir biéu mé tuyén tuy. Céng vige chan doan va dieu tri nay can phai duge xem xét da chuyén khoa véi surtham gia cia chan doan hinh anh, ndi soi can thigp, ngoai Khoa, hod tri, xa tri, giai phdu bénb, tw van di truyén, cham séc gidm nhe... 1. Djch 8 Theo Globocan 2020, ung thu tuy ding thir 13 vé sé ca ung thu 2.6% (495.773 ca/nm) va ding thit 7 vé s6 tir vong do ung thu chiém 4,7% (466,003 ca'ndm) trén toan thé gigi. ang theo théng ké nay, tai Vigt Nam, ung thur tuy dimg thir 22 chiém 0,61% v6i 1.113 ca mic méi, va dimg thir 19 vé tir vong chiém 0,87%. Theo cic thing ké truée day, ung thu tuy 1 mét trong céc loai ung thu ¢é s6 tit vong cao nhit, v6i ty Ig séng thém 5 nam sau diéu tri ung thu tuy rit thap chi tir 2 - 6%.8 Tuy vay, véi nhieu tién bé trong chan doan va diéu ti, ty Ié séng thém 5 nam sau diéu ti ung thir tuy da thay déi ngoan muc ting lén mite 11% (théng ké nim 2022 ea Higp h6i Ung thir Hoa KY) 2. Yéuténguy coNguyen nhan gay ra ung thu tuy hién van chua r6 rang. Tuy nhién, nhiéu yéu t6 nguy co duoc ghi nan Lim ting ty Ié mie ung thir tuy. MOot sé héi ching ung thu di truyén duoc xéc dinh lim ting nguy co mic bénh. Dét bién gen cd lign quan dén khoang 10-15% cac TH ung thy tuy. Mét s6 dt bién gen duc ghi nhn nhu: PRSS1, STKI1, CDKN2A, CFTR, BRCA2, MLHI, APC.10 Ngoai ra, hiit thude la, tiép xite beta-Naphthylamine, Benzidine, béo phi, vim tuy man, dai thao duéng (DTD) tip 2 6 BN trén 50 tdi ciing ta ra e6 lién quan dén bénh. II. CHAN DOAN Ap dung theo khuyén eso eiin NCCN 2-2023, tuy nhién, khi dp dung tai BV Nguyén Tri Phuong ching t6i tudn theo céc nguyén tdc co ban va phii hop trong diéu kién hién cd ctia bénh vién ciing nhu y té khu vuc, trén nguyén tac cé loi nhdt cho nguoi bénh xét ca trén yéu 16 chuyén ‘mon lan chi phi Chan dodn ung the tuy chit yéu duea vio can lam sang, céc déu hiéu lam sang theéng lé dau, ving da, sut edn, uy nhién khi c6 biéu hién lam sing thi thaeémg ung the dé tién trién. Hién van chica 6 chién luge tam sodt higu qua nhém chan dodn sém bénh ndy, 06 thé do nhitng khé khiin trong viée chon déi teong can tim sodt cling nue cong cu tdm sodt. Vige chan dodn cén dia vio cdc cng cu sau day. - Hoi bénh sit va khim lam sang - Tam sodt tién sit gia dinh - CT scan véi protocol chudn (ghi cht: bén dueéi) - MRI - Siéu dm qua nbi soi da diy-té tring (EUS), két hop v6i sinh thiét (FNA hodic FNA) vd lam gidi phau bénh, - PET scan trong mét sé trudng hop cén thi - ERCP détt stent duing mét hoc dén lieu mati — mét aham gidi ép diedmg mat, c6 thé két hop v6i chai hiit té bao (Brush cytology, khi nghi K dueéng mdi) hodc sinh thiét (K Vater, K té trang) hode EUS-FNA voi K tuy. Tuy nhién, khong phdi TH tde mat néo cing buée phai dén liu truréc mé tricphi cé viém dudng mat. Holic, 6 nhieng BN cén diéu tri tan bé tro hay nang dé téng irang truéc phdu thudt. - Xem xét gidi trinh tue gen (NGS may be considered) = Twain di truyén, diéu tri dich, theo doi ton die ung the... doi voi cdc trudng hop can thiét - CA 19-9: khéng phi li khéng nguyén dac higu cia ung thu tuy Tuy nhién, néng dé CA 19-9 gitip phan biét ung the tuy véi_céc ton thuong viém mhiém kheic ctia tuy. CA 19-9 c6 thé dicang tinh gia trong m6t so TH tae mat lank tinh. Vi vay, nén thie CA 19- 9 sau gidi dp ducdng mat khi ndng dé bilirubin 6 vé mite bin duedng. Gid tri 19-9 trade va sau mé c6 teong quan chéi vai ti Ié song cén cia BN dieac phdu thuat diéu tri ung thi tuy. - N6isoi 6 bung: khi nghi ngo cé di cain (CA 19-9 > 100U/mL, u nguyén phat lin) + Gidi phdu bénh: Chan dodn mé hoc khong bat budc phai cé wrwéc phdu thude nung cain c6 truée héba tri tin bé tro hay diéu tri tam bo. © Cé thé khéo séit té bao hoc qua choc htit kim nhé (FNA) dueéi hucémg dén EUS hodic MDCT. Khi khong thé thuc hign FNA qua siéu dm ngi soi, c6 thé sinh thiet bing cdc phuong phip khdc nue sinh thiét trong long Ong tuy qua not soi dicong mat, qua ERCP, sinh thiét qua da hay qua ngi soi 6 bung. Két qué sink thiét dm tinh phdi dugc kiém chimg bang cich lap lai sinh thiét it nhat m6t lan niza.© Néu sau 2 tan sinh thiét dm tinh ma lam sang va hinh anh van goi y nhiéu dén ung the tuy thi van c6 thé xem xé1 phau thugt nhu TH bénh & ranh giéi phéw thudt triét dé. - Déinh gié vi can thigp dinh dong - Déinh gié tong trang theo ECOG . - Déinh gid chute nding céc co quan, céc béah di kém va t6i wu hod trwde md - Ap dung ERAS © Ghi chi: Tiéu chudn CT scan chudn trong ung thie tuy Thong so Chi tiet [Loai may ‘Xoan Oc (tot nhat 1a may quét hang 64 [Do day Lat cat ‘Cang mong cing 16, wi thiéu 3 mm, Ot nbat 1 dust 1mm (0,51 mm) ne Jairo [Khoang trong Gidng nhur d6 day Tat cit (t6t nhat la khong 6 khe hi) [Chat tuong phan) D6 twong phin trung tinh (40 (wong phan duong 6 migng co thé anh huone} lduimguéng an hinh anh duge dinh dang lai ba chiéu [3D] va hinh chiéu cudng 46 ti MIP) liv [D6 trong phan Thuée can quang cé chita i-6t (t6t ahat 1a nong dé cao [>300 mg VL]) voi té ldo tiém 3-5 mLigif Cé thé sirdung 46 tong phan néng dé thip hon néu ap dung} lcii dit Kv thap. [Thoi gian quét_| Giai doan nhu mo tuy 6 40-50 gidy va giai doan tinh mach cira 6 65-70 gidy, sau khi bat dau tiém thude can quang, [Taitaovahién | Hinh anh true va dinh dang lai nhieu mit phing (9 vanh va theo s@ thich cia [thi hinh anh [to chirc, mat phang sagittal) 6 tai tao khoang cach 2 dén 3 mm 3. Phan giai doan ung thir tuy (theo AJCC 8th) 3.1. Phin logi TNM. Khoi u nguyén phat (T) - Tx: khéng xée dinh doe u ~ T0: khéng cé u nguyén phat - Tis: carcinoma tai cl - TI: wkhu tri & tuy, duedng kinh < 2em * Ta: u khu tri 6 tuy, dudng kinh $0,5cm + T1b: u khu trit &tuy, 0,Sem < diedng kinh < Jem * Tle: u khu trit 6 tuy, Lem dem - T4: uxdm lén ding mach thin tang, déng mach mac treo trang trén, hode déng mach gan chung — bat ké kich thedc khdi u Hach (N) - Nx: khong danh gié dueote hach ving V0: khong di céin hach ving = NI: di cain 1-3 hach ving = N2: di cin = 4 hach ving Di cin xa (M) - MO: khong di cain xa = MI: di cain xa Xép giai doan -0: TisNOMO TINOMO