1 T VN Ung th i trc trng (UTTT) l mt bnh lý ỏc tớnh thng gp Theo thng kờ ca t chc ghi nhn ung th ton cu Globocan 2012, ung th i trc trng ng hng th ba s cỏc ung th nam (746.000 ca chim 10% cỏc ung th) v ng hng th hai n ( 614.000 ca, 9,2% cỏc bnh lý ung th) T l mc UTTT thay i tựy theo vựng a lý, t l mc cao nht c v New Zealand v thp nht Tõy Phi Nm 2012, c tớnh cú 694.000 ca t vong UTTT, chim 8,5% tt c cỏc nguyờn nhõn t vong ung th [1] Ti Vit Nam, theo s liu ghi nhn ung th ti cỏc vựng nm 2010, UTTT ng hng th t nam v th hai n vi t l mc chun theo tui l 19,0 v 14,7/ 100.000 dõn Ti cỏc vựng khỏc ca Vit Nam cng cú t l mc khỏc Ti H Ni, UTTT ng hng th t nam v th hai n, vi t l mc chun theo tui l 26,9 v 15,6/100.000 dõn UTTT ng hng th ba nam v th t n vi t l mc chun theo tui l 13,6 v 8,7/100.000 dõn, ti Thnh Ph H Chớ Minh [2] Nguyờn nhõn ca UTTT ó c xỏc nh l yu t mụi trng v di truyn Tuy nhiờn, nguyờn nhõn di truyn ch chim di 10% cũn li phn ln xy yu t mụi trng Trong ú, ch n nhiu tht, m ng vt, ớt ng, bộo phỡ lm tng nguy c mc UTTT, ngc li ch n nhiu cht x, rau qu ti, tng cng ng th lc lm gim nguy c mc B sung canxi v vitamin D cú th phũng nga UTTT Thuc aspirin v cỏc thuc khỏng viờm gim au khụng steroid nhúm c ch COX cú th d phũng UTTT cho cỏc trng hp cú nguy c cao [3] UTTT l mt bnh cú thi gian phỏt trin chm, din tin t nhiờn qua nhiu giai on, t nhng tn thng tin ung th nh: nhng polyp tuyn v nhng tn thng viờm tớnh ca i trc trng (TT) Sng lc UTTT da trờn yu t nguy c nh tui, viờm TT tớnh, polyp tuyn, tin s gia ỡnh vi cụng c chớnh l ni soi ng mm ó lm gim t l mc v t l t vong Ngy nay, vi s hiu bit v cỏc yu t nguy c, c ch bnh sinh ca bnh v cỏc phng tin chn oỏn ngy cng hin i nh ni soi ng mm, chp ct lp vi tớnh (CLVT), cng hng t CHT, PET-CT Cựng vi s phỏt trin ca cỏc chuyờn nghnh sinh hc phõn t, gii phu bnh, chn oỏn UTTT cú nhiu tin b ó giỳp cho vic iu tr ngy cng cú hiu qu cao hn Chuyờn ny chỳng tụi cp n cỏc phng phỏp chn oỏn UTTT, phõn tớch giỏ tr ca tng phng phỏp ó c ng dng cng nh ang c nghiờn cu hin CHN ON LM SNG UTTT thng phỏt trin õm thm khụng cú triu chng c hiu Bnh cú th c phỏt hin sm cha cú triu chng nh cỏc tets sng lc nh tỡm mỏu v AND bt thng phõn, ni soi i trc trng ng mm 1.1 Triu chng ton thõn * Mt mi: Xut hin vi t l 20%, n ung kộm, ri lon tiờu húa, thiu mỏu, au * Gy sỳt cõn: bnh cú th gy sỳt 5- 10 kg vũng n thỏng [4] * Thiu mỏu: Bnh nhõn b mt mỏu chy mỏu t u kộo di vi tớnh cht thiu mỏu nhc sc, gim nng st huyt Xột nghim thy gim hng cu v huyt sc t Thiu mỏu mc nng thng gp ung th i trng (UTT) phi Do chy mỏu r r vi s lng ớt kộo di, ngoi mỏu ó hũa ln hon ton vo phõn ú ớt lm thay i mỏu sc phõn nờn khú nhn bit 1.2 Triu chng c nng * Ri lon lu thụng rut: õy l du hiu sm, bỏo hiu ung th nhng thng hay b b qua Sm nht cú th ch l thay i thúi quen i tin, o ln gi gic i ngoi, s ln i ngoi t vi ln n vi chc ln ngy Bnh nhõn b tỏo bún, b i ngoi phõn lng, hoc xen k c tỏo bún v phõn lng [4] * i ngoi phõn cú ln mỏu: L triu chng hay gp nht ca bnh UTTT õy l triu chng quan trng bỏo hiu ung th trc trng (UTTT) Bnh nhõn cú th i ngoi mỏu ti hoc l l mỏu cỏ, tng t hoc kộo di Du hiu i ngoi phõn ln mỏu ny cú th nhm ln vi bnh tr hoc bnh l, nhng cú im khỏc bit l iu tr ni khoa khụng hoc [4] * au bng: L triu chng thng gp, au cú th u xõm ln t chc xung quanh, bỏn tc rut hoc tc rut Hi chng i ngoi phõn lng nhy mi, bỏn tc rut kiu Koenig hay gp u i trng phi Trong ú hi chng tỏo bún, bỏn tc rut hoc tc rut thng gp UTT trỏi 1.3 Triu chng thc th * Khỏm bng: cú th phỏt hin u thnh bng ung th xõm ln thnh bng S thy u bng u di cn phỳc mc hoc hch bng, di cn gan * Khỏm ton thõn: cú th phỏt hin hch ngoi vi, thng l hch thng ũn Vng da di cn gan, di cn hch rn gan gõy tc mt * Thm trc trng: õy l phng phỏp thm khỏm quan trng khụng nhng chn oỏn bnh m cũn dựng sng lc UTTT cng ng Thm khỏm trc trng cho phộp phỏt hin c v trớ, kớch thc u, mc xõm ln ca u vo t chc xung quanh Theo Nguyn Vn Hiu chớnh xỏc ca thm trc trng chn oỏn mc xõm ln ca u l 67,0% [5] NI SOI 2.1 Lch s phỏt trin ca ni soi Hypocrates l ngi u tiờn dựng mt cụng c ging nh m vt khỏm trc trng Nm 1806, Philipe Bozzini ch to v thc hnh ni soi trc trng ng cng vi ngun sỏng l nn Nm 1898 Quenu thc hin ni soi trc trng c Nm 1919 Raoul Bensaude cụng b giỏ tr ca soi trc trng iu tr Nm 1946, ng soi cng i Nm 1953, Desormaux (Phỏp) ci tin ng soi di thờm ti 25 cm vi ỏnh sỏng lnh Nm 1957, Mutsunaga (Nht) s dng ng soi mm thm khỏm i trng Nm 1966, Overholl thc hin soi i trng ng mm vt kớnh M T nhng nm 80, mỏy soi mm camera, c gi l mỏy ni soi truyn hỡnh in t VEE (Video-endoscopie-electronique), i thay th ng soi mm vt kớnh ó lc hu Mỏy soi truyn hỡnh u vit hn, thun tin cho thy thuc, cho phộp chn oỏn chớnh xỏc hn, khỏch quan hn vỡ mỏy cú phõn gii cao hn, cú kh nng phúng i rừ hn, cho phộp nhiu ngi cựng tham gia ỏnh giỏ tn thng, cú kh nng lu tr v chp li nh Hin nay, nhng thnh tu v tin hc, k thut s ang c ng dng vo ni soi Nhng tin b v mỏy soi, k thut soi ó giỳp cho chn oỏn ung th ngy cng hon thin.Trong lnh vc iu tr, ni soi cho phộp thc hin c mt s can thip nh ct polyp 2.2 Soi trc trng bng ng cng Soi trc trng ng cng cho n l phng phỏp quan trng chn oỏn UTTT Phng phỏp cú u im l r tin, k thut n gin, nhng li cho bit chớnh xỏc u v hỡnh dng, kớch thc v v trớ u cỏch rỡa hu mụn T ú quyt nh ct ct trc trng hay ct on trc trng bo tn c trũn hu mụn Qua ni soi thc hin bm sinh thit cú chn oỏn GPB v cú th thc hin mt s th thut nh ct polyp, hoc giỳp t u dũ siờu õm ỏnh giỏ mc xõm ln ca ung th T l bin chng ca soi ng cng thp [6] Hỡnh Dng c v minh soi trc trng ng cng 2.3 Soi i trng sigma ng mm Ni soi i trng sigma bng ng soi mm n 60cm cú th a n tn i trng xung, khụng cn thuc gim au, l mt phng phỏp tng i r tin õy l mt phng phỏp an ton, nú cú th c thc hin bi cỏc thy thuc chm súc sc khe ban u, phự hp cho vic sng lc nhng cng ng dõn s ln, c bit c s dng kt hp vi tỡm hng cu n phõn Kt qu nghiờn cu dch t hc cho thy, tm soỏt bng soi i trng sigma lm gim t l mc v t vong ca ung th on xa i trc trng [7] 2.4 Ni soi i trng ng mn 2.4.1 Vai trũ ca ni soi i trng õy l phng phỏp cú giỏ tr chn oỏn cao Qua ni soi cho phộp quan sỏt trc tip tn thng, xỏc nh c hỡnh dng, v trớ, kớch thc u, u hay nhiu , v trớ hay nhiu v trớ Ni soi khụng nhng phỏt hin UTTT giai on sm, lm sinh thit chn oỏn xỏc nh v mt gii phu bnh m cũn cú th thm dũ c ton b i trng phỏt hin cỏc tn thng phi hp [8] [9] Do vy, ni soi i trng ng mm l phng phỏp thm dũ nht khng nh hoc loi tr UTTT mt cỏch chc chn nht Sau phu thut UTTT, ni soi i trc trng phỏt hin tỏi phỏt ti chụ [10] Ni soi ung th i trng khụng ch cho phộp quan sỏt y ton b i trng, m cũn cho phộp sinh thit hoc ct b tn thng nghi ng lm xột nghim gii phu bnh, v nú c xem l tiờu chun vng cho vic ỏnh giỏ i trng v mụ bnh hc Mt vi nghiờn cu gn õy gi ý rng tm quan trng ca ni soi i trng ang tng lờn vic sng lc ung th i trc trng [8] [10] Trong 50 bnh nhõn cú u phn gn ca i trng tin trin, cú 23 bnh nhõn khụng tỡm thy cỏc polyp (46%) Vỡ vy cỏc u phn gn nhng bnh nhõn ny s khụng c phỏt hin nu vic ỏnh giỏ ton b i trng khụng c thc hin nhng bnh nhõn phỏt hin cỏc polyp phn xa Nghiờn cu cng cho thy rng mt polyp vi bt k kớch thc v bt k loi no u cú liờn quan vi vic tng nguy c u phn gn [10] Ngoi nhng li ớch ca nú nh l mt phng phỏp sng lc, ni soi i trng cũn mt hn nh l chin lc d phũng iu ny ó c gi ý bi vic tỡm thy chng c t nhng nghiờn cu khỏc nhau, bao gm nghiờn cu Hoa K, v d liu khỏc Chõu u v Nht Bn Núi chung, nhng bnh nhõn thc hin ni soi i trng v ni soi i trng sigma cú ct polyp thỡ ớt cú kh nng phỏt sinh ung th i trc trng c so sỏnh vi nhúm chng, vi s gim cú ý ngha v ton b nguy c [8] [11] Hin nay, ni soi i trng ó c cụng nhn v li ớch ca nú nh l mt phng thc sng lc v kh nng d phũng, khong thi gian gia ln ni soi theo dừi ti u nhng ngi cú nguy c trung bỡnh hoc nhng bnh nhõn cú cỏc yu t nguy c i vi ung th i trc trng cha c thit lp [10] 2.4.2 Phõn loi cỏc hỡnh nh tn thng qua ni soi: Theo A.Hecht (1980): ni soi i trng cú th gp cỏc hỡnh nh sau: + Niờm mc bỡnh thng: trn lỏng, mu hng, búng + Niờm mc bc mu, niờm mc xung huyt + Niờm mc xut huyt lm tm + Nhy ph trờn nn niờm mc bỡnh thng hoc cú bin i + Vt trt niờm mc: loột niờm mc kốm chy mỏu, hoc khụng chy mỏu + Khi u nhiu hỡnh dng, kớch thc, mu sc, cú th kốm theo loột hoc xut huyt + Polyp nhn, cựng mu vi niờm mc bỡnh thng, kớch thc khỏc cú cung hoc khụng cung, n hoc a polyp + Tr ni, tr ngoi, sa niờm mc trc trng, dũ hu mụn, nt hu mụn Trong nhng nm gn õy, vi s phỏt trin ca khoa hc k thut, vic ng dng cỏc thnh tu ú vo ni soi i trng nh ni soi nhum mu, ni soi vi mỏy cú phõn gii cao, ni soi vi gii ỏnh sỏng hp (NBI) giỳp cho ni soi i trng cú kt qu tt hn, c bit vic phỏt hin ung th i trng giai on sm [9] Trong ni soi i trc trng, hỡnh nh ung th c chia lm loi: ung th giai on sm (Typ 0) v giai on tin trin (giai on mun, c phõn loi t typ I typ V) 2.4.2.1 Ung th i trc trng giai on sm trờn ni soi Ung th i trc trng sm c nh ngha l mt ung th c gii hn gia lp niờm mc v h niờm mc [9] [12] Ung th i trng sm cú th xy mt polyp tuyn v cú th l khú khn phõn bit mt polyp u tuyn ó chuyn ỏc tớnh hay cha Loi ny cng rt khú chn oỏn sm bng cỏch s dng chp khung i trng n thun Do ú, iu quan trng l phi quan sỏt nhng tn thng rt cn thn trờn ni soi v tin hnh sinh thit chn oỏn Ung th i trc trng sm thng khụng cú biu hin triu chng lõm sng [9] Trờn ni soi i trng, hỡnh nh UTTT giai on sm c da theo phõn loi ca hip hi ung th Nht Bn v ca phõn loi Paris õy l hai phõn loi c ng dng rng rói nht hin [9] Theo phõn loi ca Nht Bn [9]: - Typ I: loi li, chia lm typ ph + Ip: cú cung + Isp: loi cú cung ph + Is: khụng cú cung - Typ II: loi phng, cng cú typ ph + IIa: phng li + IIb: phng lừm + IIc: lừm Hỡnh Phõn loi ung th i trc trng sm theo Hip hi ni soi Nht Bn [9] Hỡnh Hỡnh nh ung th i trng sm typ IIc trờn ni soi thng v nhum mu Hỡnh Hỡnh nh ung th i trng sm typ hn hp IIa + IIc 10 trờn ni soi thng v nhum mu 2.4.2.2 Ung th i trc trng giai on tin trin Giai on ny, trờn ni soi, hỡnh nh ung th i trc trng chia lm typ Typ 1: tn thng dng li Typ 2: tn thng dng loột, cú tn thng xung quang rừ rng Typ 3: tn thng l mt vt loột bt thng, tn thng xung quanh vt loột khụng rừ rng Typ 4: mc phự n, xung huyt, hp lũng i trng, nhng khụng thy loột Typ 5: tn thng khụng c xp vo typ trờn Hỡnh Mụ hỡnh tuyp ung th i trng tin trin trờn ni soi [9] Loi l loi ph bin nht ca ung th i trc trng tin trin, ụi hỡnh nh ca typ II ch l hp lũng i trng v khụng phi lỳc no cng thy loột trờn ni soi Typ IV rt khú khn chn oỏn vỡ ung th c bao ph bi niờm mc bỡnh thng Hỡnh Hỡnh nh th ung th i trng tin trin trờn ni soi [9] 21 - Bit húa va: 50-95% t bo to cu trỳc ng tuyn - Kộm bit húa: 5-50% t bo to cu trỳc ng tuyn - Khụng bit húa: < 5% t bo to cu trỳc ng tuyn 4.6 Phõn loi giai on ung th i trc trng theo gii phu bnh Trong ung th i trc trng cú nhiu cỏch phõn loi giai on, mụi loi cú nhng u im riờng Nhỡn chung, tt c cỏc cỏch phõn loi giai on u da theo mc xõm ln v di cn ca ung th 4.6.1 Phõn loi Dukes Nm 1932, Culhbert Dukes nh gii phu bnh hc ca Vin St Mark (Anh) ln u tiờn xut phõn ung th i trc trng lm giai on A, B, C, sau ny b sung thờm giai on D [30] [31] [32] [34] + Giai on A: ung th xõm ln ti lp c gii hn thnh i trc trng, cha di cn hch + Giai on B: ung th xõm ln mc n t chc xung quanh nhng cha di cn hch + Giai on C: cú di cn hch + Giai on D: di cn xa Phõn loi Dukes l phõn loi giai on n gin nht nhng cú giỏ tr ỏnh giỏ tiờn lng Cho n nay, phỏc iu tr ung th i trc trng cũn da trờn giai on Dukes Phu thut n thun cho giai on A, B, giai on Dukes C cn phi cú x tr hoc hoỏ tr sau m lm tng thờm kt qu sng cũn 4.6.2 Phõn loi Astler - Coller Nm 1954, Astler v sau ny l Coller ó ci tin sa i phõn loi giai on Dukes [30] [31] [32] + Giai on A: u gii hn niờm mc v di niờm, cha di cn hch + Giai on B1: u xõm ln, gii hn lp c, cha di cn hch 22 + Giai on B2: u xõm ln qua lp c n t chc xung quanh, cha di cn hch + Giai on C1: u cha xõm ln ht thnh ca trc trng nhng cú di cn hch + Giai on C2: u ó xõm ln qua thnh trc trng v cú di cn hch Phõn loi Astler v Coller giỳp nhiu cho ỏnh giỏ tiờn lng So vi phõn loi Dukes c in, phõn loi Astler - Coller chi tit hn, c nhiu nc ng dng vo iu tr ung th i trc trng 4.6.3 Phõn loi ca Gunderson v Sosin Phõn loi ca Gunderson v Sosin chi tit hn phõn loi ca Astler nhng cũn ớt c ng dng lõm sng [30] [31] + Giai on A : u gii hn niờm mc + Giai on B1: u gii hn lp c + Giai on B2: u vt qua lp c ti mc song cha vt quỏ mc + Giai on B3: u vt quỏ mc + Giai on C1, C2, C3: tng ng vi B nhng cú kốm theo di cn hch 4.6.4 Phõn loi TNM Nm 1943, Denoix nh ung th hc ni ting, ln u tiờn xut giai on TNM Nm 1954, Hip hi chng ung th quc t (UICC) cụng b phõn loi TNM cho 28 bnh ung th T ú h thng TNM chớnh thc c ỏp dng trờn ton th gii Hng nm mt y ban c bit ca UICC xem xột, sa i, chnh lý, hoc phõn loi TNM mi cho phự hp hn Phõn loi TNM theo Hip hi phong chng ung th quc t 2010 (UICC 2010) [35] [36] 23 - T: u nguyờn phỏt: + Tx: Khụng th ỏnh giỏ c u nguyờn phỏt + T0: Khụng cú bng chng ca u nguyờn phỏt + Tis: ung th ti chụ, cha phỏ v mng ỏy, khu trỳ niờm mc + T1: u xõm ln lp di niờm + T2: u xõm ln lp c + T3: u xõm ln qua lp c ti mc hoc n vựng mụ quanh quanh trc trng khụng c ph phỳc mc + T4: Khi u xõm ln trc tip vo c quan khỏc hoc cu trỳc k cn v, hoc thng phỳc mc tng T4a: U xõm ln qua mc T4b: U xõm ln n cỏc c quan lõn cn - N: hch vựng: + Nx: Khụng th ỏnh giỏ c cỏc hch vựng + N0: cha di cn hch vựng + N1: di cn 1-3 hch vựng N1a: di cn hch N1b: di cn 2-3 hch N1c: nhõn lng ng di mc hoc mc treo + N2: di cn t hch vựng tr lờn N2a: di cn hch vựng N2b: di cn hch vựng tr lờn - M: di cn xa: + Mx: khụng th ỏnh giỏ c di cn xa + M0: cha di cn + M1: cú di cn xa M1a: di cn xa ch mt c quan 24 M1b: di cn nhiu c quan, hoc lan trn phỳc mc Phõn loi giai on bnh theo TNM [36] * Giai on (Stage 0): cỏc t bo bt thng xut hin lp niờm mc lũng trc trng, cỏc t bo ny cú th phỏt trin thnh ung th ri lan rng, cũn gi l carcinoma ti chụ Giai on ny tng ng Tis, N0, M0 Hỡnh Hỡnh nh mụ phng ung th i trc trng giai on [Ngun: terese winslow llc 2011] * Giai on (Stage 1): ó hỡnh thnh t bo ung th lp niờm mc, sau ú tip tc xõm ln xung lp cn niờm mc v lp c phớa di lp niờm mc Giai on ny tng ng T1 N0 M0, T2 N0 M0 Hỡnh Hỡnh nh mụ phng ung th i trc trng giai on [Ngun: terese winslow llc 2011] 25 * Giai on 2: chia lm giai on nh - IIA: ung th qua lp c nhng cha xõm ln mc, tng ng T3 N0 M0 - IIB: ung th qua lp mc, nhng cha xõm ln n cỏc c quan gn ú, tng ng T4a N0 M0 -IIC: ung th xõm ln cỏc c quan lõn cn, tng ng T4b N0 M0 Hỡnh 10 Hỡnh nh mụ phng ung th i trc trng giai on [Ngun: terese winslow llc 2011] * Giai on (Stage 3): Gm cú - Giai on IIIA: tng ng T1/T2 N1 M0; T1 N2a M0 Hỡnh 11 Hỡnh nh mụ phng ung th i trc trng giai on 3A [Ngun: terese winslow llc 2011] 26 - Giai on IIIB: tng ng T3/T4a N1 M0; T2/T3 N2a M0, T1/T2 N2b M0 Hỡnh 12 Hỡnh nh mụ phng ung th i trc trng giai on 3B [Ngun: terese winslow llc 2011] - Giai on IIIC: tng ng T4a N2a M0; T3/T4a N2b M0, T4b N1/N2 M0 Hỡnh 13 Hỡnh nh mụ phng ung th i trc trng giai on 3C [Ngun: terese winslow llc 2011] * Giai on (Stage 4) gm cú: - IVA: Ung th cú th lõy lan qua thnh i trc trng v cú th ó lõy lan n cỏc c quan hoc cỏc hch bch huyt gn ú Ung th ó lan rng n mt c quan m khụng phi l gn i trc trng, chng hn nh gan, phi, - IVB: Ung th ó lan rng n nhiu hn mt c quan xa 27 KT LUN Ung th i trc trng l bnh tin trin chm qua nhiu giai on vy cú th c chn oỏn sm Bnh cú th cú nhng triu chng bỏo trc nh thay i thúi quen i tin, ri lon lu thụng rut v i ngoi phõn cú mỏu Vi s i ca ni soi ng mm l bc tin di chn oỏn ung th i trc trng Qua ni soi cho phộp quan sỏt trc tip tn thng, xỏc nh c hỡnh dng, v trớ, kớch thc u Ni soi khụng nhng phỏt hin UTTT giai on sm, lm sinh thit chn oỏn xỏc nh v mt gii phu bnh m cũn cú th thm dũ c ton b i trng phỏt hin cỏc tn thng phi hp Cỏc phng phỏp chn oỏn hỡnh nh nh hp CLVT, CHT, ni soi siờm õm cho phộp ỏnh giỏ u, mc xõm ln, di cn hch v di cn xa PET/CT l mt k thut chn oỏn hin i vi nhy cao, giỳp ỏnh giỏ cỏc tn thng di cn chớnh xỏc hn phỏt v giỳp phỏt hin tỏi phỏt nhng bnh nhõn cú tng CEA m khụng phỏt tn thng bng cỏc phng phỏp khỏc Ni soi i trng o v viờn nang ni soi giỳp cho kho sỏt khung i trng khụng xõm ln nhng nhc im ca nú l khụng th thc hin sinh thit cng nh cỏc can thip khỏc Ngy nay, vi s hiu bit sõu sc v bnh kt hp cỏc phng tin chn oỏn ngy cng hin i nh ni soi ng mm, CLVT, CHT, PET-CT Cựng vi s phỏt trin ca cỏc chuyờn nghnh sinh hc phõn t, gii phu bnh, chn oỏn UTTT ngy cng chớnh xỏc giỳp cho vic iu tr ngy cng hon thin hn TI LIấU THAM KHO GLOBOCAN IARC (2012), Estimated Incidence, Mortality and Prevalence Worldwide http://globocan.iarc.fr/Pages/online.aspx Nguyn Bỏ c, Bựi Diu, Trn Vn Thun (2010) Tỡnh hỡnh mc ung th ti Vit Nam qua s liu vựng ghi nhn giai on 2004-2008 Tp Ung th hc Vit Nam, 1, 73-80 Sandra Van Schaeybroeck, Mark Lawler, B Johnston et al (2014) Colorectal cancer, Abeloff's Clinical Oncology, 5th edition, Elsivier, Philadelphia, 1662-1745 Nguyn Vn Hiu (2015) Ung th trc trng Ung th hc, Nh xut bn Y Hc, trang 206-226 Nguyn Vn Hiu (2000) Nghiờn cu xõm ln cua ung th trc trng qua lõm sng, ni soi v siờu õm ni trc trng Lun ỏn tin s y hc, hc Y H Ni H th M (1994) Nhn xet kt qu qua 1230 ln soi trc trng ti bnh vin a khoa Thỏi Nguyờn 1984-1988 Lun tt nghip bỏc s chuyờn khoa II Trng i hc Y h Ni Newcomb PA, Storer BE, Morimoto LM et al (2003) Long-term efficacy of sigmoidoscopy in the reduction of colorectal cancer incidence J Natl cancer Inst, 95, 622-625 Gianluca Pellino (2014) Endoscopic Detection and Surgical Treatment of Colorectal Cancer in Octogenarians Journal of Gerontology & Geriatric Research, 03 (02) Hiroyuki Kato, Teruhiko Sakamoto, Hiroko Otsuka et al (2012) Endoscopic Diagnosis and Treatment for Colorectal Cancer Colorectal Cancer From Prevention to Patient Care, Publisher InTech, 2012: p.p 327 - 347, Tokyo Japan 10 R Nishihara, K Wu, P Lochhead et al (2013) Long-term colorectalcancer incidence and mortality after lower endoscopy N Engl J Med, 369 (12), 1095-1105 11 G S Giuseppe Candilio (2014) Endoscopic Detection and Surgical Treatment of Colorectal Cancer in Octogenarians Journal of Gerontology & Geriatric Research, 03 (02) 12 Marzouk O, Schofield J (2011) Review of histopathological and molecular prognostic features in colorectal cancer Cancers (Basel), (2), 2767-2810 13 M Kekelidze, L D'Errico, M Pansini et al (2013) Colorectal cancer: current imaging methods and future perspectives for the diagnosis, staging and therapeutic response evaluation World J Gastroenterol, 19 (46), 8502-8514 14 Valentin Ignatov (2004) Diagnostic Modalities in Colorectal Cancer Endoscopy, Ct and Pet Scanning, Magnetic Resonance Imaging (Mri), Endoluminal Ultrasound and Intraoperative Ultrasound." Colorectal Cancer - Surgery, Diagnostics and Treatment, Chapter 2, Licensee InTech publiser, 2004: p.p 29 - 51 15 Vừ Nguyn Thnh Nhõn (2012) CT ni soi i trng o giỏ tr tm soỏt K i trng v tn thng ngoi i trng Y Hc TP H Chớ Minh, 2012 16(1): tr 371 - 374 16 Thomas Fear, Angela Zhang v Joshua Rosenblat (2012) Colonoscopy in screening and diagnosis of colorectal cancer UWOMJ, 2012 81(2): p.p 22 - 25 17 Uzma D v Harry R (2010) The role of EUS in rectal cancer and fecal incontinece Endoscopic Ultrasound, Springer, 371-388 18 Eifel P.J, Brerek J.S, Marman M.A et al (2011) cancer of the colon and rectum cancer: princriple and practice of on cology, 9th edition, Lippincott Williams & Wilkins, Philadelphia, 1311-1330 19 Leufkens A.M, Van den Bosch M.A, Van Leeuwen M.S et al (2011) Diagnostic accuracy of computer tomography for colon cancer staging: a systematic review Scand J Gastroenterol, 46, 887-894 20 Clark R.A (1998) Imaging in gastrointestinal oncology, Oncology Imaging, McGraw-Hill, pp 147-171 21 Katharine Aitken, Yolanda Barbachano, Bhupinder Sharma et al (2012) Elevated CEA level in the asymptomatic patient with normal conventional imaging: How useful is PET-CT for the detection of colorectal cancer recurrence 22 Niekel MC, Bipat S Stoker J et al (2010) Diagnostic imaging of colorectal liver metastases with CT, MR imaging, FDG PET, and/or FDG PET/CT: a meta-analysis of prospective studies including patients who have not previously undergone treatment Radiology; 257:674 23 Nguyn Bỏ c (1997) Cỏc cht ch im u ung th - Bi ging ung th hc, Nh xut bn Y hc, tr 60-68., 24 Nguyn Quang Thỏi, on Hu Ngh v K T Hng (2000) Khỏng nguyờn ung th biu mụ phụi CEA ung th i trng trc v sau phu thut, Tp Thụng tin y dc, Hi tho quc t phũng chng ung th, tr 94-98 25 Rosen N (1997) Molecular biology of gastrointestinal cancer, cancer of the gastrointestinal tract, Cancer: principles and practice of oncology, 5th Edition, Lippincott-Raven, pp 917-980 26 Hirotoshi Kobayashi et al (2012) Sueveillance and characteristics of recurrent apter curative resection for colonrectal cancer, Colonrectal Surgical Practice, pp 89-112., 27 Miroslav Levy (2012) Follow up and recurrent of colonrectal cancer, Colonrectal cancer From prevention to patient care, pp 363- 374 28 Giovanni Lanza (2011) Endoscopic Diagnosis and Treatment for Colorectal Cancer Colorectal Cancer From Prevention to Patient Care, Publisher InTech, 2012: p.p 327 - 347 29 Carolyn C Compton (2003) Colorectal Carcinoma: Diagnostic, Prognostic, and Molecular Features." Mod Pathol 2003 16(4): p.p 376 - 388 30 Giacomo Puppa (2010) TNM Staging System of Colorectal Carcinoma Arch Pathol Lab Med, 2010 134: p.p 837 850 31 Hamilton S R (2008) Tumours of the Colon and Rectum, Adenocarcinoma, Published by Springer, 2008(6): p.p 104 120 32 Jass J R (2007) Classification of colorectal cancer based on correlation of clinical, morphological and molecular features Histopathology, 2007 50: p.p 113 - 130 33 Fred T Bosman v Fatima Carnerio (2010) WHO Classification of Tumours of the Digesstive System Colon and Rectum 34 Maurice B Loughrey (2014) Standards and datasets for reporting cancers Dataset for colorectal cancer histopathology reports The Royal College of Pathologists, 2014: p.p 47 35 FL Obrocea, Mmaria Sain v Cristina Marinescu (2011) Colorectal cancer and the 7th revision of the TNM staging system: review of changes and suggestions for uniform pathologic reporting 36 Union for International Cancer Control (2010).T NM Classification of Malignant Tumours 7th, Colon and rec tum B GIO DC V O TO B Y T TRNG I HOC Y H NI NGUYấN VIấT LONG CHẩN ĐOáN UNG THƯ ĐạI TRựC TRàNG CHUYấN TIN SI H NI - 2016 B GIO DC V O TO B Y T TRNG I HOC Y H NI NGUYấN VIấT LONG CHẩN ĐOáN UNG THƯ ĐạI TRựC TRàNG Thy hng dn khoa hc: PGS.TS Lờ Vn Qung Cho ti: ỏnh giỏ kờt qu iu tr ung th i trc trng di cn gan bng t nhit song cao tõn kờt hp vi hoa chõt ton thõn Chuyờn ngnh: Ung th Mó s: 62720149 CHUYấN TIN SI H NI - 2016 DANH MC CC T VIT TT CEA CHT CLVT CT TT PET/CT UTBM UTT UTTTP UTTT Carcino Embryonic Antigen Cng hng t Ct lp vi tớnh Computer Tomography i trc trng Positron Emision Tomography/Computed Tomography Ung th biu mụ Ung th i trng Ung th i trc trng Ung th trc trng MC LC DANH MC HèNH