He tiet nieu binh thirong 2 3 5

Bang 9-1. Cac so do than binh thudng d ngudi ldn

Nam Nff

Chieu dai than (cm) 11.3 + /-0.8 10.8 + /- 1.0

Chieu day nhu mo (mm) 14.8 +/-(). 17(11-18) 13.6+/- 1 (11-16)

The tich bang quang thirong dtfdc danh gia hang 3 chieu theo cong thtfc:1 V V N

The tich hang quang (ml) = chieu doc x chieu ngang x chieu trtfdc-sau (cm) x 0.56.

B. Bien doi giai phiu binh thifdng

- Hinh thuy bao thai: do than dtfdc tao thanh trong bao thai tir nhieu thuy hdp lai, co the gia seo di chtfng cua viem than khu tru, la hinh lom mong tir bao than vao vo than cl gitfa cac thap than (Hinh 9-4A).

- Than hinh btfdu lac da: vo than day loi khu tru bao than, co the gia mot u than, nhtfng cau true am giong vung vo vung khac, thtfdng gap d than trai (Hinh 9-5A).

- Phi dai cot Bertin: do cot Bertin vung vo to lan sau vao vung xoangs ° O ' /

than, cung co the gia u than, nhtfng khong loi bao than va co cau true am giong vung vo ke can (Hinh 9-5B).

y 1 V

- Than doi: Than doi co the la hoan toan gom co 2 than rieng biet vdi■>

dai be than va nieu quan rieng, hoac khong hoan loan chi phan chia dai be than d ron than. Than doi khong hoan toan kho phat hien tren sieu am. hinh anh gdi y la hai ntfa cua dai be than dtfdc ngan each bdi mot vung vo than binh thirdng (Hinh 9-5C). Neu eo hai nieu quan (kho thay tren sieu am, trtf khi co gian). thi co the co hinh sa loi nieu quan trong bang quang cua nieu quan cua than tren va no co the kem theo gian dai be than.

- Be than ngoai xoang: hinh "phinh" be (han ngoai than, phia trong xoang than, chtfa dich trong thay ro tren ldp cat ngang qua ron than (Hinh 9-5D).

- Than quay khong hoan toan: be than va cac nieu quan nam d phia trtfdc.

- Than sa: nam thap (thtfdng bC'n phai). cho ndi be than co the bi gap goc.

- Than lac cho: nam d tieu khung hoac bat cheo sang ben ddi dien.

2 3 6 Ch9. Sieu am he tiet nieu

thudng nam d duoi than binh thtfdng, kem co dinh ha\ khong dinh vdi nhau.

- Than hinh mong ngtfa: hai than nam moi ben cua bung nhtfng cifc dtfdi cua chung dinh nhau qua dtfdng gitfa hdi dai nhu mo hoac moxd.

- Than nho, teo nho: co the gia than nho bcnh Iv mac phai- Bat san than bam sinh: khong thay than vung ho than va trong 6

bung.

Hinh 9-5. A. Than hinh bi/du lac da gia u.

B. Phi dai cot Bertin.

C. Hinh than doi co hai dai be than (mui ten) do vao nieu quan duy nhat (chup UIV).

D. Than phai co hinh "phinh'' be than ngoai xoang. cac dai than khong gian khong nen nham voi u' nud'c than.

II. NANG VA BENH NANG THAN

A. Nang than don thuan

Nang va benh nang than 2 3 7

Thifdng gap nhat trong cac khoi d than, chiem khoang 5CK# dan so, tan suat gapN 7 /

tang dan theo tuoi. Nang thtfdng khong trieu chtfng, so ltfdng ddn doc hoac nhieu.

Sieu am dien hinh: vo mong va nhan, chtfa dich trong am. tang sang phia sau9 / / ' ■> r

(Hinh 9-6A). Tang sang nay co the kho thay neu co md quanh than nam d phia1 / / T t

sau nang, thay doi htfdng cat giup thay ro hdn. Kich thtfdc nang thay doi. co the tdi 10 cm. Co the gap bien chtfng chay mau hoac nhiem trung vdi mtfc am vang thap. Co the co voi hoa vo nang, can phan biet vdi ton thtfdng nang ac tinh (Hinh 9-6B).

B. Benh than da nang di truyen troiGap d ngtfdi trtfdng thanh, co tien stf gia dinh, gay ra suy than tien trien.

*> V

Sieu am dien hinh: hai than to ra va co nhieu nang kich thtfdc khac nhau (Hinh 9-7A). Thtfdng phoi hdp thay cac nang d gan (50%), va co the ca d tuy. lach.

Hinh 9-6. A. Nang than ddn thuan cd tang sang phia sau (dau mui ten).

B. Nang than chua voi hoa sau boi nhi§m, theo ddi hinh luon on dinh.

C. Benh than da nang di truyen lan

Gap tre sd sinh va tre nho, bieu hien suy than. Hai than to ra. tang am do co \ 6

so phan hdi am ttf vo so thanh nang kem tang truyen am phia sau. mot so trtfdng hdp co the co \ icn giam am ngoai vi (Hinh 9-7B).

D. Benh nang than mac phai

Gap tren benh nhan loe mau keo dai.

Nhieu nang than giong nhtf bcnh than da nang di truyen troi d ngtfdi trtfdng thanh (Hinh 9-7C) .

2 3 8 Ch9. Sieu am he tiet nieu

E. Than loan san nhieu nangLa henh ly bam sinh cua than, to chtfc than dtfdc thay the hoan tuan bdi nangkich thirdc khac nhau. Neu xay ra d hai than thi gay thai ltfu. Than teo dan theotuoi, den tuoi trtfdng thanh co the nho kho tim thay, gay nham la bat san than.

/ ■> /

Than ben doi dien thtfcfng phi dai va co the co hoi chirng noi be than-nieuquan.

Hinh 9-7. A. Benh than da nang di truyen troi, than to chua day cac nang kich thudc khac nhau.

B. Benh than da nang di truyen lan d tre sci sinh vdi than to tang am dien hinh. ngoai vi co vien giam am (mui ten)

C. Benh nang than m4c phai co suy than man dude loe mau keo dai.

III. U THAN KHU TRU LANH TINH

A. U m<5-cc(-mach

Ton thtfdng co chufa m a ch m a u , to chufc cd v a m 3 nhtf dung ten goi cua khoi. nam trong nhu mo than hinh khoi thtfdng tron. tang am. dong nhat (Hinh 9-8A).

U than khu tru lanh tinh 2 3 9

/ / 1 9 v • s 2Do khoi doi am ro vdi nhu mo than nen ton thirdng nho vai mm cung co the phat hien dtfdc. Thudng ddn doc, khdng trieu chC'ng, phat hien tinh cd. ton

9 9 / _ 7

thtfdng ldn cd the chay mau gay ra dai mau hoac dau. U nay cd the phdi hdp vdi9 ' ' v * • Vxd ctfng cu, neu thay cd nhieu khdi va hai hen.

9 O ' ^

Chan doan phan biet cd the khd vdi u than ac tinh. dac biet tren benh nhan co dai mau. U md-cd-mach thtfdng nhd hdn va ddi khi co can am phia sau. Chup cat ldp vi tinh giup phan biet bang phat hien ty trong md trong u.

C

Hinh 9-8. A. U mtf-cd-mach.

B. U tuyen.

C. Oncocytoma (mui ten).

B. U tuyen (adenoma)La u lanh tinh xuat phat ttf te bao thtfdng bi dng than, thtfdng nhd < 3 cm. Sieu am thtfdng thay khdi tang am, gidi han rd (Hinh 9-8B). giong nhtf u md-cd-mach hoac u than ac tinh. Phan biet vdi ung thtf than thtfdng khd. nga\ ca tren md benh hoc.

2 4 0 Ch9. Sieu am he tiet nieu

C. U te b£o hat (Oncocytoma)U co nguon goc tir ong lirdn gan. Sieu am thirdng thay la khdi giam am. bd d£*u,

gidi han rd (Hinh 9-8C). cd the cd seo "hinh sao” d trung tam.

IV. U HE TIET NIEU A C TINH

Sieu am. thirdng la tham kham dau tien tren benh nhan co dai mau. cd dd nhay cao trong viec phat hien u than tren 2.5 cm dirdng kinh va phan biet u vdi nang than. Khoi nho hcfn sieu am thtfcfng kho phat hien do khdi thirdng ddng am. nhifng catldp vi tinh va cong hirdng tir nhay hdn.

A. Ung thi/ bieu mo te b£o than (RCC - Renal Cell Carcinoma)Hay gap nhat trong cac loai u than ac tinh. it thay d bang quang va nieu quan.

Khdi ldn thirdng gay bien dang hinh thai than. Cau true am da hinh thai vaN / 1

thirdng khdng ddng nhat cd the giam am. tang am cd nhufng vung thoai hoa nang va vdi hoa (Hinh 9-9A, B, C). Cd the lan vao tinh mach than cung ben va tinh mach chu dirdi. Doppler cho thay trong khdi cd tang sinh mach ngoan ngoeo. ddng chay tang. Khdi nhd tang am cd the nham vdi u md-cd-mach. cd the phan biet ung thu" thirdng cd bd khdng rd.

B. Ung thi/ bieu md te b£o chuyen tiep (Transitional Cell Carcinoma)Thirdng gap nhat trong u bang quang. it thay trong dirdng bai xuat cua than va nieu quan. Thirdng bieu hien dai mau ngay ca khi u con nhd. Chan doan tot nhat dira vao ndi soi.

U d bang quang sieu am thirdng de dang thay do dtfdc nirdc tieu bao quanh (Hinh 9-10A). cd the danh gia mtfc do xam lan thanh.

Neu u d he thong bai xuat cua than, thirdng nhd, ddng nhat va tirdng ddi giam am, cd the thay gian dai than phia tren. U thirdng bd sot tren sieu am. inr khi

•>

tham kham that ky tren benh nhan cd bieu hien cac trieu chufng nghi ngd. U cd the giong nhir phi dai cot Bertin. U ldn xam lan nhu md than va trd len khd phan

biet vdi ung thir bieu md te bao than bang sieu am. U thirdng lan tran tdi bang

quang va toan bd dirdng bai xuat nen can tham kham he thong dtfdng nieu.

C. U lympho

Ton thifdng tai than cua Lymphoma non-Hodgkin hoac Hodgkin khdng phai khdng hiem gap va tuy theo giai doan cua benh. Sieu am u bieu hien da dang: ddn ddc hoac nhieu khdi, thifdng giam am nhirng cd the rong am. tang am hoac hdn hdp (Hinh 9-1 OB).

Hinh 9*9. Ung thu1 bieu mo te bao than, da dang ve cau true am: giam am (A); hon hop chu yeu tang am (B); voi hoa co bong can trong u (C).

Hinh 9-10. A. Ung thu' bang quang.

B. U lympho than hai khoi (mui ten).

24 2 Ch9. Sieu am he tiet nieu

V. GIAN VA BIT TAC HE T H O N G DAI BE THAN/ i \ / •>

Khong phai tat ca gian dai he than deu la tac nghen benh ly, ma co the la gian khongdo t3c nghen. Ngtfdc lai, khong phai tat ca benh ly tac nghen deu gay gian dai hethan.

A. Gian sinh lyGian nhe he thong bai xuat thtfdng gap nhat, chu yeu la do thtf phat cua bang

1 1 > 9 t

quang cang qua mtfc. Kiem tra sau di tieu. dai be than trd ve binh thtfdng. Be than ngoai xoang la gian khong tac nghen va dUdc coi la bien doi binh thirdng. trtfdng hdp nay he thong bai xuat trong than khdng gian (Hinh 9-5D).

1 /

Co thai la nguyen nhan khac thtfdng gap cua gian nhe dai be than, chu yeu gap ben phai, dac biet d nhtfng thang cuoi cua thdi ky thai nghen. Nguyen nhan mot phan la do thai chen ep vao nieu quan va mot phan la do hormone.

B. Benh tiet nieu tac nghen/ ✓ ✓ -> *> %

Tac nghen than, nhat la neu keo dai, co the ton thtfdng than khdng hdi phuc.dan den suy than. Sieu am dong vai tro quan trong va la tham kham dau tien tren

/ ■> V /

benh nhan dau quan than hoac rdi loan lieu tien. Phan ldn cac trtfdng h«ip. tac nghen dtfdng nieu gay gian tren cho tac (Hinh 8-11 A, B). Nguyen nhan ga\ tac co the thay dtfdc d doc dtfdng di cua nieu quan, co the la do soi hoac u (Hinh 9- 11C). Than doi, thtfdng gian ntfa tren do bat thtfdng cho noi nieu quan - hang quang, do la tui loi nieu quan. Neu tac keo dai, vo than co the teo trd nen mong. Tien Itftfng tot neu vo than con day binh thtfdng.

C. If mu be than

U mu be than la cap cihi nieu khoa, thtfdng do tac nghen dan den nhiem trung. Lam sang co sot cao, dau ho than va ntfck: tieu co due co mu. Sieu am co the

* o _thay dich dai be than khong trong hoac co mtfc mu (Hinh 9-12A). Dan ltfu qua

/ , 1 1 V

da dtfdi sieu am la can thiet. giup khang dinh chan doan va dieu tri.

D. Tac nghen khong gay gian' 2 ~ i . . ' x . . * ' > ̂ ,

Co the gap d giai doan cap trtfdc khi gian dai be than xuat hien, vi vay can chu \ khi tren sieu am khong thay dai be than gian cung khdng loai trtf tac nghen tren benh nhan co trieu chufng cdn dau quan than, thtfdng la do soi nho di chu>en xudng nieu quan thap.

0. Noi nieu quan - bang quang

Nieu quan binh thtfdng d doan do vao bang quang co the thay tren sieu am Dong phut ntfdc tieu trong long bang quang d lo dd vao co the thay tren Doppler mau. Tham kham can than vung nay co the this bat thtfdng:

Gian va bit t ic he thong dai be than 2 4 3

Hinh 9-11. A. Than gian m ut do vita, thur phat do bit t ic thap, vo than day binh thudng cho thay t ic ban cap.

B. Than phai O’ nude, co kich thudc nho (7,2 cm), vo than tang am va mong, nhat la cu t giua, cho thay t ic man tinh.

C. Soi nieu quan doan sau bang quang, gay gian u" nude than.

- Soi ket doan nieu quan-bang quang, gay gian phia tren.- Trao ngtfdc gay gian khong thirdng xuyen nieu quan

\ ^ ✓ V V

- Tui loi nieu quan. khong co dinh do day dan va xep di. vi vav nen theo doi vai phut.

E. If nude than khdng t ie nghen

- Trao ngtfdc: La nguyen nhan hay gap nhat 0 tre em. Trao ngiTOc phoi hop vdi nhiem trung ngtfpc dong co the gay ra benh than trao ngirpc,

_ *> V

hau qua la ton thiTOng nhu mo than khong hoi phuc.- Gian sau tac nghen: Gian van ton tai mac du nguyen nhan gay tac

da dirpc loai bo.- Hoai tiif nhu than: Cac nhu than, nam vung tuv gan ke cac dai nho.

2 4 4 Ch9. Sieu am he tiet nieu

■> ✓ * / 4 / co the bj thieu mau do lien quan den oxy hoa thap trong vung ndi tuvThtfdng gap d benh nhan dai dirdng dung thudc khang viem hoacgiam dau keo dai. Cac nhu xu hirdng hoai ttf va bong ra va tu lai trongcac dai gay ra tac nghen. Sieu am kho phat hien ton thtfdng. bieuhi en cd the la cac tang rd phan biet vd tuy (Hinh 9-12B).

9 ■*

- Gian dai than bam sinh: Dai than gian do kem phat trien cac nhu than. Cac dai gian nhiTng vd than binh thirdng va nieu quan khdng

✓ ’

gian. Hiem hdn la ton thtfdng phdi hdp vdi gian nieu quan bam sinh do ldp cd nieu quan giam tnrdng lire.

Hinh 9-12. A. Than trai if nutic-mu: van am trong dai be than gian. benh nhan co sot.

B. Hoai tu' nhu than, cac dai gian va tu. giam am. bd khong d§u.

VI. VOI HOA HE TIET NIEU

Vdi hoa trong than hay gap la soi. Voi hoa nho khdng cd bong can tren sieu am. \a nam trong cac ton thirdng nhu- do lao. viem dai be than hat vang. vdi hoa than, hoac mot so u than. Soi co nhieu loai: calcium (hay gap nhat). phosphat. uric acid \asy stine.

A. Soi tiet nieu

Sdi than thirdng phat hien dtfdc bang sieu am. cd the tinh cd khdng tneu chtfng hoac sau mot cdn dau quan than gay tac hoan toan hoac khdng hoan toan dtfdng nieu. Sdi co the gay ra dai niau cung nhtf cd the phdi hdp vdi nhiem trung nieu

Sdi trong dai be than la hinh tang am va thtfdng cd bong can. Tu\ nhien N>ng can cd the kho tha\ do xoang than tang am nga\ sau sdi hoac do soi qua nho so vdi do rong cua chum song am. Soi nhd khd phat hien do lan vdi cac hinh tang am cua xoang than nhtf md. thanh mach. Soi co the gay gian tif ntfdc dtfdng bai