1. CHUYN K I TRC TRNG GiNG VIN HNG DN: THS.BS UNG VN ViT NHM:
Nguyn Quang Hiu Cn Thanh Hoa Nguyn Hng Ngc Sao Sarieng 2. Mc tiu i
cng v ung th i trc trng Cc phng php chn on. iu tr. Tin lng theo di
Case lm sng. 3. i cng v ung th i trc trng Gii phu. Dch t v cc yu t
thun li. 4. UNG TH I TRC TRNG Ung th l bnh xy ra khi cc t bo pht
trin v phn chia bt thng, khng kim sot. Ung th i-trc trng l tn gi
dng ch ung th xy ra i-trc trng. Hu ht xy ra lp nim mc, 5% xy ra lp
c. 5. TNG QUAN Hoa K (2013): Tn sut: ng hng th 4 T vong ng hng th 2
Mi mc : 96.830 ngi ung th i trng 40.000 ngi ung th trc trng T vong:
50310 ngi (theo NCCN) Vit Nam: K TT ng hng th 4 trong 10 ung th ph
bin nht c nam v n, trong K TT chim 50 60% (Theo thng k nm 2010
PGS.TS Nguyn B c _Vin trng vin phng chng ung th VN) 6. YU T NGUY C
Ln tui >50 t vn ng n t tri cy v rau xanh. n t cht x v nhiu cht
bo n nhiu cc loi tht Bo ph, tha cn Ung ru Ht thuc 7. YU T NGUY C
Tin s bn thn hoc gia nh c ngi b K i - trc trng hoc polyp i trc trng
Cc hi chng di truyn: a polyp tuyn gia nh (FAP) hoc K T di truyn
khng a polyp (HNPCC: Hereditary Non-polyposis Colon Cancer) Bnh vim
rut, bnh Crohn, bnh vim lot i trng. 8. YU T NGUY C Tin s bn thn hoc
gia nh c ngi b K i - trc trng hoc polyp i trc trng Cc hi chng di
truyn: a polyp tuyn gia nh (FAP) hoc K T di truyn khng a polyp
(HNPCC: Hereditary Non-polyposis Colon Cancer) Bnh vim rut, bnh
Crohn, bnh vim lot i trng. 9. POLYP TUYN (Adenomatous polyp) Tuyn
ng (tubular) Gp bt k on no trn i trng v c cung Nguy c c tnh khi
>2cm Tuyn nhung mao (vilous) Ch yu trc trng v khng cung Nguy c c
tnh cao nht Tuyn ng- nhung mao (tubulovilous) Nguy c c tnh ty thnh
phn nhung mao trong polyp Nguy c c tnh khi >2cm Chim 10% polyp
xut pht t lp biu m ca i trng 10. POLYP TUYN (Adenomatous polyp) 11.
CC HI CHNG DI TRUYN: a polyp tuyn gia nh (FAP) K T di truyn khng a
polyp (HNPCC) 12. HI CHNG FAP (Familial Adenomatous Polyposis
Syndrome) - Do c s t bin ca gen APC, l gen c ch s hnh thnh ca khi u
tn sinh i trng. - tui bt u xut hin l tui 16 v c chn on tui trung
bnh l 36 Nguy c ung th: Ung th i trng 100% khi n tui 40 Ung th d
dy, t trng 4% 13. HI CHNG LYNCH Ung th i trng do di truyn khng phi
a polyp (HNPCC-Hereditary Nonpolyposis Colorectal Cancer). Chim 5%
cc trng hp ung th i trc trng. t bin ca 1 trong 5 gene Mismatch
Repair Genes: MLH1, MSH2, MSH6, PMS1, PMS2. 14. HI CHNG LYNCH Nguy
c mc cc bnh l c tnh 15. GII PHU BNH 1. i th 16. 2. Vi th 90-95% l
ung th t bo tuyn vi bit ha cao, va, km. 5% ung th th keo Him hn l u
sarcom, u lympho, u carcinoid ng hu mn: ung th biu m lp Malpighi.
17. PHN LOI GIAI ON 1. Theo Dukes: Giai on A: Ung th khu tr thnh
trc trng lp nim mc v di nim mc Giai on B: Ung th lp c, thanh mc cha
di cn hnh Giai on C: Di cn hnh vng Giai on D: Di cn xa 18. PHN LOI
GIAI ON 2. Theo TNM: 19. Stage 0 (colon carcinoma in situ).
Abnormal cells are shown in the mucosa of the colon wall. 20. Stage
I colon cancer. Cancer has spread from the mucosa of the colon wall
to the muscle layer. 21. Stage II colon cancer. In stage IIA,
cancer has spread through the muscle layer of the colon wall to the
serosa. In stage IIB, cancer has spread through the serosa but has
not spread to nearby organs. In stage IIC, cancer has spread
through the serosa to nearby organs. 22. Stage IIIA colon cancer.
Cancer has spread through the mucosa of the colon wall to the
submucosa and may have spread to the muscle layer, and has spread
to one to three nearby lymph nodes or tissues near the lymph nodes.
OR, cancer has spread through the mucosa to the submucosa and four
to six nearby lymph nodes. 23. Stage IIIB colon cancer. Cancer has
spread through the muscle layer of the colon wall to the serosa or
has spread through the serosa but not to nearby organs; cancer has
spread to one to three nearby lymph nodes or to tissues near the
lymph nodes. OR, cancer has spread to the muscle layer or to the
serosa, and to four to six nearby lymph nodes. OR, cancer has
spread through the mucosa to the submucosa and may have spread to
the muscle layer; cancer has spread to seven or more nearby lymph
nodes. 24. Stage IIIC colon cancer. Cancer has spread through the
serosa of the colon wall but not to nearby organs; cancer has
spread to four to six nearby lymph nodes. OR, cancer has spread
through the muscle layer to the serosa or has spread through the
serosa but not to nearby organs; cancer has spread to seven or more
nearby lymph nodes. OR, cancer has spread through the serosa to
nearby organs and to one or more nearby lymph nodes or to tissues
near the lymph nodes. 25. Stage IV colon cancer. The cancer has
spread through the blood and lymph nodes to other parts of the
body, such as the lung, liver, abdominal wall, or ovary. 26. Giai
on Tn thng 0 Nng I T1-T2,N0,M0 Khu tr II T3-T4, N0.M0 Xm ln III T,
N1-N2, M0 Ti hch vng IV T, N, M1 Di cn xa LP NIM DI NIM LP C THANH
MC HCH DI CN XA PHI GAN ACS surgery: Principles and practice, 2007
edition HOME 27. Chn oan Lm sang Giai phu bnh Hinh anh hoc 28. 1.
LM SNG Giai on sm bnh hon ton khng c triu chng Cc triu chng c th
xut hin t ngt hoc tin trin dn 29. Gng mt to bn 30. Bun nn, nn, st
cn, mt mi, thiu mu Triu chng ca bn tc hoc tc rut au vng hu mn,
quanh hu mn Triu chng ng tiu: tiu au, tiu kh,. TRIU CHNG C NNG 31.
KHM Tng trng sinh hiu, cn nng, thiu mu S dc khung i trng Khi u, ln
nhn nhiu mi, b ko u, mt cng, di ng t, n au nu nhim trng S c khi gan
to ln nhn, bng bng v hch thng n tri 32. THM TRC TRNG U si nhiu n
cng nhng li d mn lot + nn v thnh trc trng xung quanh hi cng.
Sarcom: u y nim mc vo lng trc trng, nim mc trc trng nhn Tnh trng c
tht hu mn: tht cht hay nho Mu dnh gng 33. 2. CN LM SNG 1. Ni soi i
trc trng km sinh thit 2. CT scan, MRI, X-quang 3. Siu m 4. Xt nghim
mu 34. NI SOI I TRC TRNG KM SINH THIT L tiu chun vng chn on v tm
sot cc bnh l c tnh i trc trng u im Xc nh s lng, v tr, hnh th, kch
thc khi u Bn cht khi u qua sinh thit nhy > 95% v c hiu gn 100%
Chng ch nh Tnh trng bnh nhn nng khng chu c : suy h hp, sc Vim phc
mc 35. NI SOI I TRC TRNG KM SINH THIT 36. CT SCAN V MRI nh gi giai
on ung th Pht hin ti pht hay di cn Chn on xc nh ung th vi: BN khng
chp nhn ni soi i trng BN khng gi c baryt/ d ng baryt Tc rut do u i
trng Thng u i trng 37. Khi c m m mm, nh vo lng i trng Dy thnh i
trng > 6 cm Hp lng i trng HNH NH CA UNG TH I TRNG TRN CT 38. Ch
nh: Khi ni soi khng n c manh trng do u gy hp ng soi khng qua c Chng
ch nh: Tc rut hon ton, nght rut, thng rut X QUANG I TRNG C CN QUANG
39. Hnh hp Hnh ct ct Hnh khuyt Hnh ct ct dng cng cua HNH NH C TH
THY TRN PHIM X QUANG 40. CHP I TRNG I QUANG KP u im: Pht hin chnh
xc khi u i trng = 50 -Khng c tin s u tuyn hay ung th i trng -Khng c
tin s gia nh b ung th i trng -t 50 tui tr ln -Tm mu n trong phn hng
nm -Ni soi i trng chu hng, chp i trng cn quang mi 5 nm -Ni soi ton
b khung i trng mi 5 nm Nguy c cao: -HC Lynch, HNPCC -a polyp -Tin
cn ung th i trng, gia nh c ung th i trng -Tin cn vim lot i
trng/crohn -Ch n nhiu tht, m, HTL tu thuc yu t nguy c: -Thng 40 tui
-Nu c ngi thn b KTT nn tm sot trc 10 nm so vi tui ca ngi tr nht b
ung th trong gia nh -Ni soi i trng HOME 45. IU TR K I TRC TRNG 46.
Mc lc Nguyn tc iu tr. Cc phng php iu tr phu thut, ch nh tng phng
php i vi K i trc trng cha bin chng v c bin chng. Cc tai bin, bin
chng ca phu thut. Khi no cn ha tr, x tr. Tin lng 47. NGUYN TC IU TR
NGOI KHOA 1. Ct rng ri on rut c khi u, km mc treo i trc trng, hch
vng v cc tng 2. Tn trng k thut ct cch ly khng ng u (Turnbull R.B,
1967) 3. Chun b tt i trng ni ngay sau khi ct, lp li lu thng tiu ha.
48. NGUYN TC IU TR NGOI KHOA 49. NGUYN TC IU TR NGOI KHOA 50. NGUYN
TC IU TR NGOI KHOA 51. NGUYN TC IU TR NGOI KHOA 52. PHNG PHP IU TR
PHU THUT Phu thut trit Phu thut m rng Phu thut lm sch Phu thut tm b
53. PHU THUT TRIT Bnh nhn th trng tt Ung th cha di cn xa (giai on
I, II, III theo TNM) Ung th khu tr thnh rut cha xm ln cc tng xung
quanh hoc c xm ln nhng cn kh nng ct b c 54. PHU THUT TRIT Ct i trng
phi: Ch nh: Ung th i trng phi: Manh trng i trng ln i trng gc gan on
i trng ngang bn phi cch gc gan 0 5cm 55. PHU THUT TRIT Ct i trng
phi: Ct ton b T phi: 20cm cui ca hi trng manh trng T ln T gc gan
1/3 hoc 1/2 bn phi ca T ngang ty v tr u Ct mc treo T phi vi mch mu,
hch mc treo Ni hi trng vi T ngang 56. PHU THUT TRIT Ct i trng phi:
https://www.youtube.com/watch?v=FqfqeYfLMEM 57. PHU THUT TRIT Tai
bin PT ct i trng phi: Rch t trng t hoc khu tht niu qun (P) Rch TM
ch di Bin chng sau m: Bc x ming ni gy VPM, r phn Vim khoang t bo
sau PM Tiu lng 58. PHU THUT TRIT Ct i trng tri: Ch nh: Ung th i
trng tri: on i trng ngang bn tri cch gc lch 0 5cm i trng gc lch i
trng xung Phn u T chu hng 59. PHU THUT TRIT Ct i trng tri: Ct ton b
T tri: 1/2 T ngang bn T T gc lch T xung phn u T chu hng Ct mc treo
T tri vi mch mu, hch vng Ni T ngang vi T chu hng 60. PHU THUT TRIT
Tai bin PT ct i trng tri: V lch t hoc khu tht niu qun T Bin chng
sau m: Bc x ming ni gy VPM, r phn Vim khoang t bo sau PM 61. PHU
THUT TRIT Ct i trng ngang: Ch nh: Ung th on gia ca i trng ngang K
thut: Ct on T ngang Ct mc treo T ngang, - TM T gia v hch vng Ni 2 u
T ngang P v T 62. PHU THUT TRIT Tai bin PT ct i trng ngang: Tn thng
t trng, ty him khi xy ra Bin chng sau m: Bc x ming ni gy VPM, r phn
63. PHU THUT TRIT Ct i trng chu hng: Ch nh: Ung th on i trng chu
hng K thut: Ct on T chu hng trn v di khi u t nht 5cm Ly mc treo vng
Ni 2 u T xung v trc trng 64. PHU THUT TRIT Tai bin PT ct i trng chu
hng: Tn thng niu qun T, -TM h v Bin chng sau m: Bc x ming ni gy
VPM, r phn 65. PHU THUT M RNG Th trng bn tt Ung th xm ln hoc di cn
m cn c th ct b c 66. PHU THUT M RNG Ct b rng rai trit , kt hp ct cc
c quan ln cn b xm ln v ct mt phn hay ton b cc c quan b di cn 67.
PHU THUT TM B Ung th giai on tr khng phu thut trit c (giai on IV
theo TNM) Th trng bnh nhn qu km khng th chu c cuc phu thut ln 68.
PHU THUT TM B Ni tc on trn v on di khi u Hu mn nhn to trn dng
https://www.youtube.com/watch?v=C8ESeoSN-Ro 69. IU TR K I TRNG C
BIN CHNG K i trng c bin chng Tc rut T phi Ct v ni ngay T tri Ct, hn
ch ni ngay Vim phc mc HMNT trn dng Ct u R vo cc c quan ln cn HMNT
trn dng Ct u Xut huyt tiu ho di nng Ct b i trng c khi u 70. PHU
THUT K TRC TRNG Ct trc trng gi c vng Phu thut Hartmann Phu thut ko
tut Phu thut Miles 71. CT TRC TRNG GI C VNG, KHU NI BNG MY ACS 2007
edition 72. PHU THUT HARTMANN 73. PHC HI LU THNG RUT SAU PT
HARTMANN 74. PHU THUT MILES Ti HMNT Ung th v cc m gn b loi b Ung th
u tn lm HMNT 75. GIAI ON CH NH Giai on 0 Phu thut Giai on 1 Phu
thut Giai on 2 Phu thut Ho x b tc sau m Giai on 3 X tr trc m Phu
thut Ho x b tc sau m Giai on 4 v ung th ti pht Phu thut hoc ho x
(vi tnh cht thuyn gim) Ho x b tc sau m Theo Colon cancer, rectal
cancer NCI 02/2014 K I TRNG 76. Giai on Ch nh Giai on 1 PT ct trc
trng bo tn c vng hu mn PT ct trc trng theo ng bng - tng sinh mn
(APR PT Miles) Ct ti ch qua ng hu mn km x tr quanh khu vc PT (EBRT)
v s dng 5-FU Giai on 2 1 trong 3 la chn PT : - PT bo tn c tht - PT
Miles - PT on chu Ho x tr b tc sau m Colon cancer, rectal cancer
NCI 02/2014 K TRC TRNG 77. Giai on Ch nh Giai on 3 1 trong 4 la chn
: - PT bo tn c tht - PT Miles - PT on chu Ho- x thuyn gim X tr trc
m Ho x tr b tc Giai on 4 v ung th ti pht 4 la chn: - Ct u vi tnh
cht thuyn gim, ni tt hay lm HMNT - t stent qua ch hp - Ct cc khi di
cn bit lp gan, phi, bung trng Ho x thuyn gim Ho x b tc Colon
cancer, rectal cancer NCI 02/2014 K TRC TRNG 78. K TRC TRNG C BIN
CHNG Tc rut Vim phc mc R vo c quan ln cn LM HU MN NHN TO TRN DNG
HOME c 79. THEO DI SAU M Bin chng sau m: Bin chng sm: Ngy 1: chy mu
bng, vt m. Ngy 3, 4: nhim trng. Mt s bin chng khc: Hu mn nhn to ng
tit niu Tim mch, h hp (nht l BN ln tui ) 80. CH IU TR SAU M: iu tr
sm. iu tr b sung 81. IU TR SAU M Nhn n nui n bng ng tnh mch 82. IU
TR SAU M Khng sinh sau m 83. IU TR SAU M Gim au 84. IU TR SAU M Chm
sc ng dn lu v thay bng 85. K HOCH THEO DI LU DI Thm khm LS: mi 3-6
thng trong 2 nm u tin mi 6 thng trong nm 3, 4 v 5. CEA mi 3-6 thng
trong 2 nm u . Ni soi TT: 3-6 thng trong 3 nm u mi 6 thng cho 2 nm
tip CT mi nm trong 5 nm Theo Colon cancer , rectal cancer- NCCN
2.2015 HOME c 86. BOO-FACT Bowel habit Observe Ostomy F2: Familly
10y/FOB Exon (KRAS) Age Colonoscopy Toucher rectal 87. CASE LM SNG
88. PBL: Tha bc s, ti c b sao khng? 89. - Cc cc cc! - Mi c vo! Cu
chuyn xy ra ti mt phng khm a khoa, ni bc s Trung ang cng tc. M ca
bc vo l mt ngi ph n tm 40, nc da sm thng thy ca nhng ngi bung ba di
ci nng oi . C ngi xung gh v gii thiu: - Tha bc s, ti tn Tin, 45t,
lm ngh bun bn ph liu. - C b sao m n khm? - Tha bc s, ti b tiu chy!
90. Bn s chn on v x tr g? 91. - Ch i tiu phn nh th no? - Tha bc s,
ti i cu phn chy nc. Bnh thng th ti thng bn nhng thnh thong ti mi i
phn chy nc nh vy. Phn th vng. Mt ngy ti i 2, 3 ln. Cm gic au bng
ch. Ngi ph n ly tay m phn bng di. - Ch c st khng? - Tha bc s, ti
thy ngi cng m m, khng r. - Ch c thng xuyn b tiu chy khng? - Tha
khng, ch thnh thong. 1,2 thng ti b mt ln. Vn n thc n nh bnh thng.
Khng n mn g l c. 92. Bn s chn on v x tr g? 93. - Trng hp ca ch ti
ngh ch b ri lon tiu ho. Ti s cho thuc ch v ung trong 5 ngy, sau nu
c g khc l ch hy quay li, ti s kim tra thm. - Vng tha bc s. Ch nhn
ngi bc s ln tui, ang suy ngh vit n thuc, ch thy lng an tm phn no. n
thuc ng qua, ch thy vi ch cipro, smecta 94. Mt thng sau, ch quay
li, ln ny ch c v m hn ln trc. Ch th th: - Tha bc s, mt thng nay ti
b tiu chy thng xuyn hn, xen k to bn. Ti thy st 4 kg. Khng bit c sao
khng. Trong cc ln bn, c 1,2 ln ti thy c chy mu, ti khng bit c b tr
khng? - Ch n ung nh th no? Ch n c g thay i khng? - Ti thng n tht ba
ri, c t du m mi lm vic c, cng hay n rau luc ny n. Nhng ti cng hi lo
bc s . Ti c ngi bc h b ung th rut gi mi mt hi thng trc, m bc nghe
ni u b hi nm 50 tui, cng b tiu chy ging vy. Tui lo lng khng bit c
sao khng. V bc s m chiu, nhn bnh nhn, suy ngh. - Ch trc tin hy nm
ln bn khm, ti c vi vic mun kim tra. Vic khm hon tt. Da nim nht. Bng
n khng im au. TR: khng mu dnh gng, khng u si trc trng. 95. - Ti ngh
ch cn lm vi xt nghim. - Vng tha bc s. Cm mt s phiu i xt nghim, ch
Tin lo lng, khng bit mnh c b sao hay khng. Nhn ln tri, mt bu tri
xam xm nh sp ma. 96. Theo cc bn cn lm thm cc xt nghim g hay khng?
97. Kt qu: CTM: wbc: 9.16k/ul, Neu 69,4% Rbc 4.16M/ul, hgb
10.4g/dl, hct 32.3%, Mcv 79.8fl, mch 25pg, plt 417k/ul Chc nng
gan-thn, men gan cha thy bt thng. Chc nng ng mu, xt nghim nc tiu
cha thy bt thng. HBsAg (-), anti-HCV (-) 98. Kt qu: FOB (+) CA 19-9
20U/ML CEA: 303.2 ng/ml 99. Chn on v cc bc x tr tip theo? 100. Ti
liu tham kho Colon cancer - NCCN 2.2015 Rectal cancer- NCCN 2.2015
Bnh hoc ngoi khoa tiu ha B mn Ngoi HYD 2013 Phc iu tr K trc trng BV
HYD 2011 iu tr ngoi khoa tiu ha B mn Ngoi HYD 2007 NCCN colon and
rectal cancer 2/2015
http://www.cancer.gov/types/colorectal/patient/colon-treatment-
pdq#section/all 101. CM N THY V CC BN!
