🔙 Quay lại trang tải sách pdf ebook Lâm sàng phụ khoa và giải phẩu bệnh Ebooks Nhóm Zalo GS.BS. OINH VAN TUNG, FACOG, FASCP lA m sA n g p h u k h o a vA g i a i p h A u b e n h IflM SANG PHU KHOfl v a Glffl PHfiU B€NH B ien dich ban sach xuat bcin Ian thu hai GS.BS. DINH VAN TUNG MD, FACOG, FASCP Giao su San phu khoa Giao su Giai ph6u benh Bo m on San phu - T rtfan g D a i hpc Y G alve to n - Texas 0^1 HQC THAI TKJNG TAM HQC L illi N ha xu at ban Y hpc Hd Noi - 2003 Bien dich: - BS. DANG THE CAN - BS. NGUYEN PHI HUNG - BS. DAO TIEN C'U'C - BS. TRAN NAM THANG - BS. TRAN VAN THUAN SYLLABUS OI GYNECOLOGIC PATHOLOGY WITH CLINK AI CO R RE L A T IO N S L()I t u a LAN XUAT BAN LAN THL/ 2 Trong nhieu nam, giao su' Dinh da say me nghien cu'u nganh giai phau benh phu khoa, va gianh nhieu cong sue trong viec giang day bo mon nay cho cac sinh vien y khoa va bac si noi tru chuyen khoa. Toi cung ehia se niem say me eua ong va cung nhu ong deu tiec khi thay hien nay tain quan trong eua viec giang day giai phau benh phu khoa cho sinh vien y khoa va bac sT noi tru chuyen khoa chua du'oc chu y. Su' hieu biet nhung van de co ban ve giai phau benh phu khoa hoan loan la dieu can thiet doi vo'i nhung thay thuoc lain sang ve cac benh phu nu'. Neu khong co nen tang nay thi ngu'di thay thuoc lam sang se khong the phat trien von hieu biet ve lich sir tu' nhien cua can benh va nhung nguyen tac chii'a tri. Lan xuat ban thir hai cuon sach nay la mot su' thanh cong xuat sac. No rat de doc va lam theo, no con cung cap rat nhieu thong tin va nhu'ng dieu quy bau. Theo y kien toi. cuon sach nay la giao trinh ma tat ca sinh vien deu phai hoc trong qua trinh hoc san phu khoa cung nhu' bac si noi tru du'oc dao tao ve Ilnh vuc nay. Cac thay thuoc chuyen khoa lam sang trong thirc hanh cung se lam tot hon khi co cuon sach nay trong tay nhu' mot tai lieu tra cu'u nhanh. Cuon sach du'oc vict tot. chinh xac va nhieu thong tin. Moi chirong deu co bang tra cu'u rieng tong hop de ngu'di doc quan tam co the tra cu'u them nhung thong tin chi tiet. Raymond H. Kaufman MI) Truong dai hoc Y khoa Baylor Houston, Texas 1. Am ho■ I. Ban thai hoc II. Mo hoc III. Cac benh da thirong gap IV. Cac ton thirong am ho trong cac benh he thong V. Nhiem trung VI. Cac u lanh tinh VII. Cac ton thu'ong bieu mo khong u VIII. Cac t6n thu'ong noi bieu mo u IX. Cac u ac tinh xam nhap I. Bao thai hoc A. Bo phan sinh due ngoai bat dau bang mot giai doan khong biet hoa d tuan thur 4. Cu sinh due. cac nep nieu due va cac loi biu- am ho deu co nguon goc tir ngoai bi. B. C ac dac tru'ng v& gidi duo'c xac d in h o' tu a n thu' 9. Co' q u a n sinh d u e ngoai diroc hinh t h a n h d a y du o' tu a n thu' 12. C. Cu sinh due hinh thanh am vat. nep nieu- due hinh thanh cac moi nho, loi biu- am ho hinh thanh cac moi Ion. mu va cac mep sau am ho. D. Cac tuyen Bartholin: Duo'c hinh thanh tir xoang nieu - due (co nguon goc noi bi). tuo'ng ung voi cac tuyen hanh nieu dao o' nam. E. Tien dinh: La viing giua mang trinh va moi nho. du'o'c gidi han bdi ham moi am ho d phia sau. Am dao va nieu dao md ra d day. Tien dinh co nguon goc noi bi. II. Mo hoc (da) A. Moi Ion • Thu'ong bi duo'c tao bdi bieu mo vay lat tang • Chan bi cd cac nang long va ba loai tuyen - Tuyen nguyen ven (tuyen mo hoi) - Tuyen toan buy (tuyen ba) - Tuyen ban buy. la tuyen dac hieu cho cac \iing am ho, quanh ong hau mon, nach va vu. Bat dau che tie! theo chu ky khi co kinh nguyet, gom cac te bao Ion co bao tirong mau hong. B. Moi nho Khac vo'i moi Ion, lop bieu mo cua moi nho khong co lop hat. khong co nang long, it tuyen tiet rung d^u. cac tuyen ba do thans len be mat da. C. Am vat • Gom hai the hang ( mo cu'ong mach) • Khac vo'i dirong vat la khong co the xop. D. Cac tuyen Bartholin (cac tuyen ti£n dinh chfnh) • Cac tuyen tui: Duo'c tao boi cac te bao bieu mo tru che nhay. • Cac ong du’oc lot boi cac te bao chuyen tiep. • Mieng ong du’oc lot boi bieu mo lat tang giong cua am dao. • Cac tuyen phu vung lien dinh: o xung quanh tien dinh. • La vung duy nhat cua ong sinh due nu' co nguon goc noi bi. E. Nieu dao • Duo'c lot boi bieu mo chuyen tiep. 16 nieu dao dirge lot boi bieu mo lat tang. • Cac ong Skene (khong phai tuyen) a lo nieu dao diroc lot boi bieu mo vay. • Nieu dao phia ngoai co cac tuyen nho bao quanh (la noi hay bi nhiem trung va hinh thanh cac nang). III. Cac benh da thuong gap A. \ iem da tiep \uc (viem am ho phan irng) • Do kich thich tai cho: nu'oc hoa. thuoc \it. mvi ton>_: hop cac dung cu tranh thai am dao... • Da viem phu lie do. • Di6u in: Loai ho cac tac nhan gay benh. dung cac Corticosteroid tai cho de giam ngu'a. B. Viem da man tinh - Dai the: T6n thu'ong co mau hoi do, xam hoac trang (giong voi qua san bieu mo vay hoac loan dirdng tang san ngu’di gia) - Vi the: Day sung, tang gai, xam nhap viem man tmh. - Dieu trj: Rita hoac boi kern Fluorinated Corticosteroid, tiem diro'i da Triamcinolone. C. H am - Vet nut cua da bj ngam trong cac nep gap gian dui va gian moi a cac benh nhan beo phi. - DiSu tri: Tranh am, giam beo, chong ngu'a bang Eurex hoac cac corticosteroid tai cho. D. Benh vay nen - Dai the: Cac mang do da du'oc bao phu boi cac vay bac min (dau hieu Auspitz). Cac mang do da co the xuat hien 6 cac vung khac nliau tren co' the. o' am ho ton thirong co the bi che lap boi sir am u'ol va co the giong vo'i mot viem da khong dac hieu. - Vi the: A sung, mao bieu mo thong noi hinh truy va hinh tlion dai. lop bieu mo tren cac nhu mong. nhieu mao mach trong cac nhu chan bi. Khong co ap- xe Munro trong lop thuo'ng bi - Dieu tri: Cac Corticosteroid Fluorinated tai cho nhu Cyclosporine, Methotrexate. Trong tnrdng hop phiic tap nen tliam kliao cac bac sy da lieu. E. Benh nam da dui • Nliiem trung be mat o' ben va plian tren dm do cac nam da. thirong ket hop \6'i nam da 6 cac \i tri khac (ngon chan..\\ ) • I’on thu'ong do da kliu till, bogioi han ro. Ngu'a tir n den nhieu. • Dieu tri: Dung mo Imidazole F. Liken phang • Dai the: San tnn phang. thuong la cac mang trang o' am ho, co the t6n thuong o' am dao. • Vi the: Tang sung, tang gai. xam nhap limpho dang dai sat lop thu'ong bl • Dieu tri: Mo Corticosteroid. IV. Cac ton thuong am ho trong cac benh he thong A. Benh Crohn • Hiern khi tcm thuong am ho. • Dai the: Hinh thanh duong do true trang day chau hoac true trang am dao va cac xoang din. • Vi the: Xam nhap viem va u hat khong hoai tii ba dau • Dieu tri: N hu vo'i benh Crohn (khang sinh, Metronidazole va Steroid truoc va sau khi su' tri cac duo'ng do). B. Benh Behcet • Nguyen nhan: Khong r5, co the la benh tir rnidn hoac do virut. • Dac tru'ng boi mot hoi chung gom 3 trieu chung: Loet o' mieng, co' quan sinh due ngoai va mat. • Mo hoc: Xam nhap viem day dac va viem mach. nhieu mao mach bi tac. • Dieu tri: Corticosteroid. C. Dai tliao duong • Viem am ho do nam Candida albicans. • Giai doan cap: Ban do 6 moi Ion va nho. • Giai doan man: Thuong bl day man xam va loet. • Ditjii tri: Cac thuoc chong nam hien tai va kiem snai dai thao duo'ng. 10 D. Thieu mau man • Loet am ho. E. Lire huyet • . Cac mang mau vang nau a co' quan sinh due ngoai. F. Lao am ho • Rat hiem. do true khuain lao. • Do nhiim true tiep tir ban tinh bi benh hoac do su lan rong theo duang mau, hoac theo ducrng true tiep tir voi triing, noi mac tir cung. • Dai the’: Cue loet 6 cac moi am ho hoac o vung tien dinh, bo' ngo&n ngoeo meo mo. • Vi the: Cac nang lao hoai tir ba dau kinh di6n co true khuan ua a xit. • Dieu tri: Thuoc chong lao. V. Nhiem trung A. Giang mai • Benh hoa li£u. gay ra bo'i Treponema Pallidum, Anaerobic Spirochete. • Mo ta ton thuong: - T6n thuong nguyen phat (sang) ► U benh 3 tuan. ► Dai the: T6n thuong cung khong dau. co loet a giua. co the gap nhieu t6n thuong o' cac moi am ho hoac lo vao am dao. Viem hach ben khong hoa mu. ► Vi the: Phan ung viem cap va man tfnh. phan ung viem quanh mach mau 1 0 ret, co rat nhieu tuong bao va xoan khuan trong t6n thuong. Ton thuong giai doan II (u loi phang) 1 1 ► Xuat hien sau ton thuong nguyen phat tir 6 tuan den 6 thang. ► Dai the:: Hinh anh hoai tu mau xam, loi cao hinh cao nguyen. ► Vi the: Tang gai, qua san bieu mo, cac te bao viem man vdi rat nhieu tuong bao. viem dong mach. Tim thay nhieu xoan khuain trong t6n thuong. - T6n thuong giai doan III (gom hoac loet) ► Hiem gap, xuat hien sau vai thang den mot nam ke tir khi nhidm benh ducri dang cac u gom hoac cac vet loet. ► Vi the: U hat vo'i cac te bao khong 16, cac te bao dan nhan va dang bieu mo. Tang sinh manh mao mach va day thanh mach. Xam nhap tuang bao ro ret. • Chan doan: Kfnh hien vi nen den, thir huyet thanh (RPR, VDRL) va xet nghiem hap thu khang the Treponema danh dau bang huynh quang (FTA- ABS). • Di6u tri: Benzathin, Penicillin hoac Tetracyclin, Doxycyclin. Benzathin Penicillin hoac Erythromycin khi co thai. Giai man cam cho cac benh nhan di ung vori Penicillin. B. Ha cam • Hiem gap, gay ra boi Hemophilus ducreyi, mot loai vi khuan gram am khong chuyen dong tren tieu ban va trong moi truang nuoi cay. • U benh: Tir 3- 10 ngay. • Dai the: Loet don doc hoac nhieu o, bo meo mo khong deu kern viem hach ben. sang mem dau. tang cam. • Vi the: Phan ung viem man vo'i nhieu limpho bao va tuong bao. • Chan doan: Nhuom gram va nuoi cay dich mu • Dieu tri: Azithromycin, Ceitriaxon. Ciprofloxacin. Ervthromvcin C. U hat ben (donovanosis) • Hiem gap, gay ra boi Calymmatobacterium granulomatis, true khuain hinh que co vo. gram am, thuoc ho Enterobacteriaceae. • U benh: 1-12 tuan • Dai the: Khoi dau la vet san mem nho, lan rong do loet be mat doc theo vung ben mu. loet khong dau, bo go cao. Co the co mot ton thuong a giai doan tien ac tinh trong giai doan man tinh cua benh. • Vi the: Phan ung viem man vo'i cac mo bao (te bao u hat), doi khi co qua san dang gia u bieu mo voi bi6u hien tang gai bat thuong, thuan thuc bat thuong o cac dinh mao thuong bi. Cac the’ Donovan trong cac mo bao lorn hoc hoa. • Chan doan: Cac th£ Donovan trong cac te bao don nhan tren cac phien do hoac cac mSu benh pham lay ra tir o loet. • Dieu tri: Tetracyclin, Ampicillin, Chloramphenicol trong 2-3 tuan. D. U hat Iimpho hoa lieu (benh Nicolas- Favre). • Gay ra boi Chlamydia trachomatis tip L. • U benh 4- 21 ngay. • Dai the: Thu'ong bat dau bang nhung vet loet nho de bi bo qua va mot viem hach ben r5 ret. Tien trie!n thanh phu am ho va cac xoang bach mach dan den hep true trang va nieu dao. Co kha nang ac tinh o' giai doan man tinh (can sinh thiet). • Vi the: Xam nhap cac tuong bao va te bao don nhan Ion. gian bach mach va tang sinh noi mo. Tang sinh dang gia u bieu mo co the gap. • Chain doan: Bang cay mil hoac tim thay Chlamydia vo'i cac moi a-xit nhan. • Dieu tri: Tetracyclin, Doxycyclin, Erythromycin. Azythromycin, Ofloxacin. Choc hut cac hach hoa mu. khong chfch rach hoac d in liru. E. Herpes • La cac nhiem trung thong thuong do \irut Herpes simplex gay ra, the loai Hominis tip 2 hoac 1 (thuong gap tip 2). • U benh: 3 den 7 ngay • Dai the: Cac bong nuoc, sau do la cac o loet rat dau, thinh thoang ket hop voi phu am ho va cac hach ben thuong sung to, mem. • Sinh thiet: Cac te bao co nhieu nhan Ion co cac th£ vui ai toan trong nhan • Te bao hoc: Cac te bao co nhidu nhan hinh kinh m o ( ton thuong nguyen phat) va co cac the vui trong nhan o the: tai phat. • Chain doan h iu het dua vao te bao va nuoi cay • Dieu tri: Dung Betadine tai ch6, uong Acyclovir, Valacyclovis, hoac Famci- clovir. • Tliii thuat cesar o cac phu nu mang thai neu cac t6n thuong hoat dong. F. U mem lay • Do pox virut • Dai the: Cac khoi u tir 5- 8mm, lom o giua, ngua. thuong thanh dam. • Vi the’: Tang gai. lom cua lop thuong bi ( lam dong tien 0 trung tarn); trong te bao co cac the1 vui ( the' vui u mdm). • Di^u tri : Nao bo hoac dot dien . • Ton thuong co the thoai trien mot cach ngiu nhien. G. Mao ga • Loai ton thirong pho bien, gay ra boi virut sinh u nhu 6 nguoi. ( thuong la HPV 6/1 1). • U benh : 1- 8 thang, trung b'inh 3 thang. • Dai the: U I6i don doc hoac nhiem diem khap am ho. • Vi thei: Tang sung, a sung, benh u nhu. tang gai, te bao co vong sang quanh nhan va viem man 6 lop chan bi. • Di6u tri: Phiu thuat Lazer, dong dien, phiu thuat lanh, phau thuat rong, Podophyllin trong con thuoc Benzoin axit trichloracetic, mo Imiquimod, Gel Podofilox (chong chi dinh dung thuoc khi co thai). • Nen thuc hien thu thuat cesar trong truong hop mao ga Ian rong. Khong the ngan chan u nhu o' hong ti e so sinh bang thu thuat nay. • Khong sinh thiet t6n thuong mao ga truoc 2 tuan sau khi dieu tri bang Podophyllin vi t6n thuong co the giong ung thu bieu mo tai ch6. H. Viem tuven mo hoi mu • Nhilm trung tuyen ban huy do Staphylococus aureus. • Cac cuc du'o'i da dau am i. Cac cuc nay co the’ thong noi thanh dam. t6n thuong tuong tu' nhu o' nach. • Dieu tri : Trich rach hoac mo' rong vung da bi nhiem khuan va dung kliang sinh. I. Benh Fox Fordyce • Do cac tuyen ban huy bi tac. • Dai the: Cac not san nho ngu'a chac, loi len mat da. • Vi the: Xam nhap viem. gian cac tuyen tiii. tiet dich phu vao mo ke can. • Dieu tri : Uong th uoc tranh thai va d u n g th u o c giam ngu'a tai ch6 J. Viem tuyen tien dinh • Cac tuyen nho 6 tien dinh sirng to thanh mot vong quanh lo vao am dao. • Viem gay ra cam giac dau rat bong va dau khi giao hop . • Tren cac manh sinh thiet. bie:u mo chuyen tiep cua cac ong d in co the bi hieu nham la ung thu bielu mo tai cho. • Dieu tri: Cat bo neu co trieu chung. VI. Cac u lanh tinh A. Nang • Nang ong Bartholin - Do tac va gian ong - Nang duo'c lot bo'i bieu mo chuyen tiep hoac bieu mo det tu cac tuyen tui tiet nhay lan can cua tuyen Bartholin. - Co the bi nhiem khuan bo'i Neisseria. Staphylococcus, hoac cac tac nhan khac va tao thanh ap-xe tuyen Bartholin. - Dieu tri: Thong tui hoac dat catheter trong vong 4-6 tuan. • Nang nhay: - Duo'c lot boi bieu mo tiet nhay hinh tru hoac hinh khoi - Sinh ra tu' cac xoang nieu due ton du h oac tu cac tuyen tien dinh - Dieu tri: Cat bo • Cac nang cua ong Nuck trong ong ben (cac n ans duo'c lot boi phuc mac hoac trail dich am ho) - Tuong tu trail dich tilling tinh - Tha\ 6 moi Ion hoac 6 ong ben. - Sinh ra do phuc mac bi viii doc theo da\ chane iron. 16 - Dieu tri: Cat va that tui thong noi vo'i khoang phuc mac (chan doan phan hiet voi thoat vi. sung hach ben. tinh hoan lac cho) • Cac nang bieu bi vui Duo'c lot bo'i mot lop bieu mo vay sung hoa min. nang chira chat ba dac - Do cac ong tuyen ba bi tac hoac do cac vet thuong vui bieu mo vao trong (thu thuat rach am ho). - Di6u tri: Cat bo neu co trieu chung. • Nang ong Skene: - Cac nang nho canh nieu dao. hiem khi gay tac nieu dao. - Du'oc lot boi bieu mo chuyen tiep - Dieu tri: Cat bo neu nang Ion B. U dac • Mun com co cuong (da tua. polfp xo bieu mo) - Dai the: U lanh. co cuong hoac khong. co the co kich tlurdc Ion. - Vi the: Thu'ong bi binh thu'ong vo'i mo xo lien ket thua (mo mo va mao mach) - Dieu tri: Cat bo non co trieu chung hoac co lo lang ac tfnh • U mau: - U mau dang qua dau ► Dai the: I 1 mem mau do loi tren mat da ( 1mm- vai cm) nhin thay sau khi sinh. co the thoai trien. ► Vi the: Gian cac mao quan o' chan bi va cac mach man moi du'oc hinh thanh. ► Dieu tri: Theo doi hoac dot lanh. dot bang laser. - U mau the h a n g ^ l H Q C T H A n ^ u Y t . s TSUNG TAM HOC LI$i l7 ► Dai the: Khoi nhieu thuy mau tim. co the lan rong van am dao. xuat hien trong vong vai thang dau sau de. I co the lan rong hoac teo di sau mot vai nam. ► Vi the: Cac khoang clni'a mau Ion khong deu. duo'c loi boi cac te bao 1101 mo. ► Dieu tri: Dot lanh. laser, hoac phau thuat cat bo. - U mau nguo'i gia(u man dang anil dao): ► Dai the: Cac san m£m, nho, lio'i do, co the ep xuong duo'c. thu'ong thay o' cac phu nu' tru'o'c va sau man kinh. ► Vi the: Cac mao quan gian du'oc lot boi cac te bao noi mo det. ► Di£u tri: Khong can dieu tri. trir khi co cha\ man ( laser, cat lanh. dot dien kho) - U mach sung ► Dai the: Ton thu'ong don doc hoac nhieu 6. mau do den. be mat san. ► Vi the: Cac mao mach bi gian nam a tren lop chan bi; Thuong bi co bieu hien tang sung. a sung, cac mao chan bi keo dai dang u nhu. ► Dieu tri: Phau tlniat cat bo u - U mach nhay tien trien. ► Dai the: Khoi mem 6 am ho ► Vi the: Rat nhieu mao quan trong mo dem nha\ Ions leo ► Dieu tri: Cat bo rong rai. U hay tai phat. - U tuyen mo hoi ► U lanh tinh cua tuyen ban huy. hiem gaponhutisj nsuoi da den ► Co the bi chan doan nham la ung ihu bieu mo tuven ► Dai the: I nho hon 2 cm. vi tri o' mo Ion hoac khe dira 2 moi IS ► Vi the: Co can true dang tuyen. gom nhieu ong nho va tuven tui, dirge lot hoi mot lop bieu mo tru ( bao tuong u'a loan, nhan hoe hoa) va mot lop te bao co' bieu mo ► Dieu tri: Phau thuat eat bo. Xet ngliiem mo hoc can than - U te bao Schwann hoac u nguyen bao co' te bao hat ► Dai I lie: U cua vo day than kinh, bieu hien la cac cuc nho (2-3cm) duoi da moi Ion. ► Vi the: U gom cac o te bao da dien Ion, kich thuoc deu, bao tuong day dac cac hat u'a toan. Tren lop thuong bi thay qua sail gia dang bieu mo giong vo'i ung thu' bieu mo vay xam nhap. ► Dieu tri: Cat rong ton thu'ong. dien cat sach. - Not ruoi (no' vi) • Dai the: Ton thuong noi chung clni'a sac to, no' vi co the khong co sac to. • Vi the: Cac o te bao no' vi co nhan tron hoac trai xoan. nam o' vung tiep giap chan bi va thuong bi ( no vi chan bi- bieu bi), chan bi (no' vi chan bi) hoac ca 2 (novi plioi hop). ► Dieu tri: Cat bo de chan doan (Chan doan phan biet vo'i ung tlnr bieu mo tai cho, u liac to hoac benh sung gai) - Benh sung gai. ► Co the giong vo'i u hac to, novi hoac ung thu bieu mo tai cho ► Dai the: Ton thuong mau den. khong trieu cluing, khong co kha nang ac tinh. Ton thu'ong man nau co the gap bat ky noi nao tren co' the. ► \ ;i the: Tang sung, tang gai. benh nliii \ a cac nang sung ► Diem tri: Cat bo de chan doan (Khong can dieu tri neu chan doan dam bao chnili xae benh) - Vii phu ► Thuong gap tloc iheo du'ong su'a bao thai (nach. ngu'c du'o'i. bung Iren). hiem klu o'am ho. ► Moi Ion phinli to. ket hop vo'i co thai. ► Ty le ac tinh cao ( 4 irudng hop ung thu vu nguyen phat o am ho da duo'c ghi nhan). ► Vi the: Giong mo vu. cac tuyen tui va ong dan ► Dieu tri: Cat bo ( Tru khi co thai) - U co' noi mac tu cung ► Do cay ghep noi mac tu cung khi de hoac phau thuat ► Dai the: Cac khoi nang mau do. xanh xam. to lcn theo chu ky. ► Vi the: Cac tuyen noi mac va mo dem. ► Dicau tri: Ph&u thuat cat bo - U ong mo hoi ► Dai the: Cac cuc mau vang hoac mau da nho. khong co trieu chung 6' ca 2 moi Ion. ► Vi the: Cac tuyen ngoai tiet bi gian. duo'c lot bo'i bieu mo lat tang vo'i cac duoi hinh dau phay 6 tan cung ► Dieu tri: Khong can dieu tri - U hat sinh mu: ► Dai the: Cue mau nan do, mau tliit. loi tren mat da. de chav mau. ► \ i the: Mo giong to chiic hat gom rat nhieu mao mach nho duo'c bao quanh bo'i mo dem phu ne. ► Dieu tri: Cat bo don thuan - U xo va u xo mo ► Dai the: Ton th u o n g chac va nhfin m au trails due hoac ghi nliat. ► \ i the: Cac bo. dai te bao \ o t h u o n g kern theo te him m 6 ► Dieu tri: Phau thuat cat bo. 20 VII. Cac ton thu’ong bieu mo khong u Duoc phan loai nam 1987 bo'i Hoi quoc te nghien cu'u cac benh am ho va Hoi quoc te cac nha GPB phu khoa, bao gom: li kern xo, qua san te bao vay va cac benh ve da khac. A. Liken xa • Thay o tat ca cac lira tu6i • Dai the: V u n g l r a n g giong giay thuoc la hoac giay da, mong. Bao am vat thuong phu ne, moi nho teo va hep loi vao am dao. • Vi the: Tang sung, bieu mo mong. mat cac cau noi chan bi, lop collagen va co cac dam te bao viem man. • Dieu tri: Cac loai mo clobetasol (steroid manh). testosterone hoac progesterone. • Ty le ac tinh thap (3,5%) B. Qua san te bao vay (Tuong duong voi loan duong tang san ) • Dai the: Cac mang mau hong sang hoac tring r5. do, co the lan rong hoac ranh gidi khong ro. • Vi the: Tang sung, tang gai, cac mao chan bi rong ra va co hinh dui cui, viem man. Khong co te bao bat thuong. • Chain doan : Sinh thiet: chan doan chu yeu bang sir loai tru. • Dieu tri: Cac Corticosteroid tai ch6. • Ty le ac tinh hoa: gan nhu bang khong trong nhung tru'ong hop khong co te bao bat thuong. VIII. Cac ton thuong noi bieu mo u A . Djnh nghia ve sir bat thuong cua bieu mo am ho. • Hinh thanh cau sung 6 cac dau tan cung cua mao chan bi hoac o' lop day. • Cac te bao bat tliuc san, khong thuan thuc trong lop bieu mo (Nhan chia. tang ty le nhan/ bao tuong). • Hinh thanh cac the’ tron (ket dac nhan co vong sang quanh nhan) B. P h a n loai cac ton thirong u noi hieu m o o a m ho. • Tan san noi bieu mo am ho (VIN). - VIN1 (loan san nhe): Bat th uong thay o' 1/3 duoi cua lop bieu mo - VIN2 (loan san vua ): Bat th uong thay o' 2/3 duoi cua lop bieu mo - VIN3: (loan san nang hoac ung thu am ho tai cho). Bat thuong te bao tren 2/3 chieu day lop bieu mo. • Benh Paget • U hie to tai ch6. C. C ac loai roi loan tan sinh noi bieu m o cua a m ho. • Tan sinh noi bieu mo am ho do III (VIN3) - Truoc day duo'c goi la benh Bowen, h6ng san Queyrat. ung thu bieu mo don thuan, san dang Bowen, ung thu bieu mo tai cho). - Dai the: Ton thuong don doc hoac nhi£u o, san hoac vet. Mau sac rat khac nhau: den, trang, xam, hong hoac do. - Vi the: 3 tip • Tip mun com ( dang u loi) - Lien quan vo'i nhieu HPV 16 v a i 8 - Bieu mo be mat co hinh Iuo'n song va hinh gai nhon - Tang sung, a sung. - Tang gai. nhan te bao da hinh thai. tang sAc. te bao khong 16. nhieu nhan. hinh nhan chia bat thuong. sung hoa te bao riena le, te bao bong. • l ip dang day - Lien quan den nhiem HPV 16 va IS - Lop thu'ong bi day len. be mat phang min - Lop hieu mo gom cac te bao can day khong thuan tliuc bat thu'ong ( giong CIN3) co rat nhieu hinh nhan chia • Tip biet hoa ( lip don gian) - Khong lien quan den nhiem HPV - Cac te bao bat thuong gidi han d phan day va can day cua cac mao bieu mo: bao tuong u'a toan ro, hinh thanh cac cau sung. • VIN3: Tip mun coin va tip dang day thuong thay o' vung ke can cua ung thu bieu mo va)' xam nhap tip mun com va dang day d cac benh nhan tie ( tuoi trung hinh 54). V1N3 tip biet hoa thay d vung ke can ung thu bieu mo vay dien hinh d cac benh nhan gia ( tuoi trung binh 77) - Dieu tri: Cat rong tai cho, dien mo sach: vo'i cac ton thuo'ng nhieu d, cat da am ho + ghep da day. Phau tluiat laser (dau. chav mau. nhiem trung nhung tham my tot hon) - Tien trien thanh ung thu' bieu mo xam nhap it gap (6r/r). Thu'ong xay ra o' cac phu nu' sau man kinh va cac benh nhan bi lie che mien dich • Benh Paget: - Hiem gap. 25% ton thuong xam nhap. (75r r ton thuong nam trong lop bieu mo), tuoi thuong gap tu 60 - 80 tuoi. - It khi ket hop vo'i ung thu bieu mo tuyeii d dudi ( khong giong vdi benh Paget cua mim vii. benh ludn Iuon di kern vdi ung thu bieu mo tuyen the noi ong cua vu): co the ket hop vdi cac ton thu'ong ac tinh khac nhu: Ling thu bieu mo phan phu cu.; da; co tir cung. vii. true trang hoac buong tiling. - Dai the: Ton thirong mau do gach. trong ed cac dam mau trang. - Vi the: Cac o te bao Paget ( te bao to. bao tuong rong. sang, co hat mm: nhan to, hat nhan ro, phan ling duong tinh vdi CEA va CK) d lop can day eua thirong bi. Ton tlurong phan phu da gap 75% cac trudng hop. Cac t6n thirong xam nhap tha\ cac te bao Paget va te bao day khong biet hoa xam nhap thang xuong mo dem ben dirdi. - Di6u tri: Cat long tai chd, ke ca lop chan bi ben dudi de loai bo cac ung thu bieu mo tuyen; trong cac trudng hop co ung thu bieu mo tuyen ket hop. cat am ho triet de va vet hach ben 2 ben. Tren luong xau d cac bieu mo co di can hach ben. - Thuong tai phat ke ca khi dien cat sach va co the dieu tr; bang laser. • U h k to tai ch6 (noi bieu mo). - Dai the: Giong u hac to ac tinh do I - Tien luong tot, 100% benh nhan song. - Di£u tri: Cat rong ton thuong IX. Cac u ac tinh xam nhap A. Chia giai doan: • Chiem tu 3 - 5% tong so cac u ac tinh cua ong sinh due • He .thong phan giai doan cua FIGO ( 1988) dua tren cac thong so phau thuat: T (khoi u). N (hach). M (di can). FIGO la ten viet tat cua Hiep hoi quoc te ve san phu khoa. - Giai doan I: U gidi han d am ho va /hoac day chau dudng kmh Ion nhat < 2 cm: khong di can hach. ► Gun iloan hr. Ton thuong < 2 cm. xam nhap mo dem < 1 mm ► Giai Joan lb: Ton thuong < 2 cm. xam nhap mo dem > I mm - Giai doan II: U gidi han d am ho va/ hoac o da\ chau: > 2 cm. khong di can hach. - Giai doan III: I bat ky kich thudc nao nhung co lan rone vao nieu dao duoi. am dao. hau mon. \ a / hoac cli can hach khu \ uc mot ben. 24 - Giai doan IV: U xam lan nieu dao tren, bang quang, true trang xuong chau va/hoac di can hach mong 2 ben va/ hoac di can xa. ► Giai doan IVa: U xam Ian bat ky mot trong nhung phin sau: Nieu dao tren, niem mac bang quang niem mac hau mon, xuong chau, va / hoac di can vung hach vung 2 ben ► Giai cloan l\ b: Khi co di can xa, ke ca hach chau. B. Ung thu bieu mo vay xam nhap be mat am ho ( 1995) • Duo'c coi la giai doan la: Ton thuong < 2 cm duong kmh, gidi han o' am ho hoac vung day chau. xam nhap mo dem < 1mm. Khong co di can hach. • Chi£u sau xam nhap duo'c do tu vung tiep giap cua bi^u mo vdi mo dem cua nhu chan bi k£ can nong nhat den diem xam nhap sau nhat. • Wilkinson: 12 trudng hop xam nhap < 1,5mm khong co tdn thuong hach, 18 trudng hop xam nhap tu 1,5- 4 mm; 2 trudng hop co di can hach (11 %). • Dieu tri: Cat rong tai chd, dien cat cach bd ton thuong 2 cm. Di can hach g i n nhu khong co. C. Ung thu bieu mo vay xam nhap • Chiem toi 90% cac u ac tinh cua am ho. 5% cac u ac tinh cua he sinh due nu'. • Benh tlurdng gap d lira tuoi 70 -90: Neu mac cac benh u hat benh xuat hien sdm hon 20 nam (1/ 25.000 d lua tuoi 60- 7<' va 1,5/ 100.000 phu nu) • Cac ton thuong bao tnrdc: VIN3: benh u hat; ngua keo dai • 21% cac ung thu bieu mo am ho d cac benh nhan gia ( tuoi trung b'mh 77) \ a 81% cac benh nhan tie ( tuoi trung binh 50) co nhiem HPV 1 6. 25 • Vi tri thuong gap: Phan tren moi Ion • Dai thd : Khoi hinh nam hoac cuc loet • Xam nhap bach mach: Hach dui va hach ben nong ( hach ti6n tram) bi xam nhap d iu tien. sau do la hach dui sau. hach chau. Ty le di can hach theo ki'ch thuoc u: < 2 cm : 20% : > 2 cm 45% (GW Morley) • Benh hoc: - Ung thu bieu mo sung hoa biet hoa cao ► Chiem 75% cac tdn thuong, gom nhung dam 16n bieu mo vay bat thuong vdi cac cau sung xam nhap trong mo dem. ► Thuong gap o’ benh nhan gia hon, ket hop vdi the don thuan cua VIN hoac qua san vay va khong chua DNA cua HPV. - Ung thu bieu mo dang day hoac mun com ► Dang day: Cac o tron Ion hoac cac dai nho te bao khong thuan thuc, co ft bao tuong va it hoac khong co sung giong vdi te bao day cua bieu mo b6 mat. ► Tip mun com: Hinh u loi ra ngoai a b£ mat. cac o te bao vay khong deu co nhan da hinh thai, bat thuong te bao ( tang sac. nhieu nhan. bat thudng te bao bong). ► Gap d cac benh nhan tie hon va ket hop vdi cac ton thuong VIN tuong ung ( dang te bao day hoac mun com). Co chua DNA cua HPV. • Dieu tri: Cat am ho triet de. vet hach dui. ben hai ben. co the tha> doi neu ton thuong mot ben. Neu di can hach ben thi nen tia xa hach chau. • Dien cat sach u va chieu sau xam nhap la yeu to du doan tai phat tai chd tot nhat. • Tinh trang hach ben la yeu to tien luong doc lap quan trong nhat. 26 • Song them khong bi anh hirong bdi muc do biet hoa cua te bao u. • Tien luong: Song them 5 nam: 70% • Giai doan 1.2 : Khong di can hach : 90% • Giai doan 1.2 : Co di can hach : 40% • Ty le song them 5 nam cua cac benh nhan co di can hach chau la 7% . D. lin g thu hieu mo the s^n • Ten khac: U loi Buschke va Lowenstein • Dai the: Tcin thuong giong u loi mao ga: xam nhap va tai phat tai cho khong di can hach. • Sinh thiet: Lay sau, lay du'o'c nhieu to chuc dem cho chan doan giai phiu benh. • Mo hoc: Cac nhu hinh gan la duoc phu bdi cac te bao bieu mo vay lat tang thuan thuc. cac mao chan bi phdng ra ep vao mo dem. Tang sung va tang gai. Khong co cac hinh anh ac tinh nhu' bat thuc san nhan ngoai tru thinh thoang co su' hinh thanh cac cau sung trong lop bieu mo nhung khong a dinh cua cac mao chan bi. Mo dem bi xam nhap bdi cac te bao viem. • Dieu tri: Cat rong tai cho. dien cat sach u. khong co di can hach trong 27 trudng hop (Japaze va cs) • Xa tri: Chong chi dinh do co kha nang chuyen dang cua cac te bao lanh thanh ac tinh. E. Ung thu bieu mo tuyen: • Hiem nhat trong cac u ac tinh cua am ho. • Sinh ra tir cac tuyen Bartholin, hoac hiem hon tu dug Skene. Cd the sinh ra tu tuyen vu lac chd. • Tuoi trung hinh: 60 -70 tuoi ( tie lion 10 tuoi so vdi ung thu bieu mo va\ o' am ho) • Vi the: Hinh anh ung thu hieu mo tuyen, thirong kern biet hoa. • Chan doan thuong m uon do hay co viem nhiem o vung nay ( nen sinh thiet neu benh nhan > 40 tudi va co viem tuyen Bartholin) • Di£u tri: Cat am ho triet de, vet hach ben va dui hai ben • Tho'i gian song them duo'c xac dinh boi giai doan 6 thai diem chan doan. F. Ung thu hieu mo dang tuven nang • Ung thu bieu mo tuyen kinh didn cua tuyen Bartholin, giong vo'i u cua tuyen nude hot ( 50% ung thu bieu mo tuven Bartholin la te bao vay). • Giai phiu benh: Cac d te bao u co nhan tang sac. tron hoac oval, bao tirong hep. sap xep dong tam thanh dang mat sang quanh cac hoc giong tuyen. • Xam nhap sau, tai phat tai ch6, va di can muon, thudng tdi phoi, hiem khi tdi hach ben. • Dieu tri: Cat rong tai chd, vet hach ben cung ben (Copeland va cs). G. Ung thu bieu mo te bao day • Chiem 2% cac ung thu am ho. • Dai the: Ton thu'ong loet. bd tron. gd cao. < 2 cm dudng kinh thudng gap d moi ldn. • Vi the: Cac dam te bao day nho sap xep dang hang dau va d6ng deu a ngoai vi. • Di can hach hiem gap ( 1 trudng hop duo'c ghi nhan) • Dieu tri: Cat rong tai chd. H. I hac to ac tinh • Loai ung thu phd bien thu 2 o' am ho, chiem 5% cac u ai tinh cua am ho 28 • D a i the: Ton thu'ong loi len. co sac to va thu'd'ng bi loet. Cd 2 tip co' ban la tip cuc va tfp lan long be mat. • Vi the: Cac hac bao bat thudng. ky quai co hoat dong ket noi. nhieu hat sac to melanin, xam nhap sau vao mo xung quanh, cd nhan chia bat thudng. Hinh anh vi the rat khac nhau. chan doan dira vao ky thuat hoa mo mien dich (S- 100. HMB- 45). • Do Clark: I. trong bieu mo; II, nhu chan bi; III. tiep giap giCia nhii chan bi va chan bi ludi: IV. chan bi 1 udi: V. m d d u d i da. • Chieu day u theo Breslow: Nguy co' thap, < 0.75mm; nguy co vua, 0,75- 1,5mm; nguy co' cao. > 1.5 mm. • Dieu tri: Cat long tai chd. cat am ho triet de. vet hach ben va dui 2 ben. doi vdi cac u co do Clark > III: vai tro cua vet hach ben cd gia tri tien lu'ong lion la dieu tri. • Tien luong: Phu thuoc vao mu'c do ton thu'ong ( Clark 1: 100% song 5 nam; Clark II: 100%: Clark III: 75%: Clark IV: 50%. Clark V: 30%). va di can hach. Neu theo chieu day u cua Breslow thi song them 8 nam vdi cac u day 1,5mm la 100%: cac u tu 1,5 - 4 m m la 65%; cac u > 4 m m la 25% . • Chet do di can lan rong toi phoi. gan. nao. • Hoa tri khong dap ling. I. C a c sacdm • Hiem. 2% cac ung thu am ho. • Benh nhan tie lion ( tudi trung binh 38 tudi). - Saconi xo. sacdm co' van. sacdm xo' than kinh. sacdm co tron ( hay gap nhat). ► Thudng cd \ u hudng tai phat tai cho. ► Dieu tri: Cat am ho triet de va vet hach ben 2 ben. ► Song them: kem - Sacdm xo' bi loi: ► U hiem gap a am ho ► Thuong tai phat tai ch6, khong di can hach ► Di£u tri: Cat rong tai ch6 J. Cac u ac tinh thir phat • Di can tu c6 tu' cung, true trang. noi mac. • Ung thu' bieu mo rau, ung thu te bao than. • U limpho ac tinh 30 2. Nieu dao ■ ■ I. Bao thai hoc II. Mo hoc III. Nhiem trung IV. Cac u lanh tinh V. Cac u ac tinh I. Bao thai hoc A. Bieu mo bat nguon tu phan noi bi bang quang cua xoang nieu due. Mot phan co the xuat phat tu trung bi cua ong trung than, nhu vay co the dap ling vdi hormon estrogen. B. To chuc lien ket va co tron phat trien tu trung bi tang lan can C. Cac tuyen quanh nieu dao va du'di nieu dao (tuong tu vdi tien liet tuyen) la su nho ra tir bieu mo cua phan dau nieu dao. II. Mo hoc A. Long ong du'oc lot bang bieu mo chuyen tiep. 16 sao du'oc lot bo'i bieu mo vay lat tang. B. Lop co' can tao gom 1 dp doc o' trong va lop vong o' ngoai: la loai co tron. III. Cac benh nhiem trung A. Nhiem trung cac ong quanh nieu dao (ong Skene) • Ong tuven Skene nam tai hinh dien sail cua Id nieu dao ncoai (mieng ong bieu mo vay: dug: bieu mb chuyen tiep). • L6 sao do, phu. Ion ra ngoai • Tac nhan: lau cau. Trichomonas. • Dieu tri: Khang sinh va Metronidazole. B. Nhi^m trung tuyen duori nieu dao • Dai the:: Tui thua duoi nieu dao do nhiem khuan tai phat man tmh. • Vi the: Viem man tinh. • Dieu tri: Khang sinh: phau thuat cat tui thua. C. Viem nang nieu dao • Lien quan toi viem • Vi the: Cac dam nho te bao bieu mo chuyen tiep bi vui, bao quanh la niem mac nhiem trung man tinh. D. Lon lo nieu dao • Xay ra d tie em gai tru'6'c day thi hoac phu nil sau man kinh, do teo niem mac lan can. • Mo nieu dao Ion mau, do, co the nham vdi u num hoac u khac. • Dieu tri tai cho bang Estrogen. II. Cac u lanh tinh A. U num • La u thudng gap nhat • Dai the: la ton thuong do. mem. dang pdlip tai Id nieu dao • Vi the: cd 3 dang: dang u nhu. dang u mach. va dang u hat (cac mach mau nho bao quanh bdi mo dem phu. tham nhiem te bao viem). • Dieu tri: cat u xet nghiem giai phau benh (nham loai tru ung thu bieu mo nieu dao). B. U loi, u nhu te bao vay, u co tron: sinh thiet. trong trudng hop nghi ngd ve loai u. Cat u tai chd. V. Cac u ac tmh A. Cd 3 loai ung thu bieu mo • Ung thu bieu mo vay: thudng gap hon cac loai khac. Gap d doan nieu dao ngoai • Ung thu' bieu ind te bao chuyen tiep. bieu the nieu dao: tuong tu nhu ung thu bieu mo nhu cua bang quang. Gap o' doan nieu dao trong hoac ngoai. • Ung thu bieu mo tuyen: hiem gap. xuat phat tir cac tuyen che nhav cua vung dudi nieu dao. B. Dieu tri cho tat ca cac ung thu bieu mo • Tia xa ke vao ton thuong trung tarn: vet hach ben. sau do tia xa tai chd va vung tieu khung neu hach ben duong tmh. • Tien luong xau: song them 5 nam toan bo la 71% neu u o' phia tru'dc va 5 0 f < neu u plna sau. C. Sacdm, u bac to. u lympbd: thudng la thu phat. rat hiem gap. D. Di can: tir cac ung thu bieu mb bang quang. am ho. am dao. cd tu cung. budng trung va ung thu nguyen bao nuoi. T3-LSPK ' “ 3. Am dao■ I. Bao thai hoc II. Mo hoc III. Cac ton thuong viem IV. Cac u lanh tinh V. Cac u ac tinh I. Bao thai hoc A. Am dao xuat phat tu' ong Muller va mot phan noi bi cua xoang nieu due. B. Cac phan thap cua ong Muller du'oc chap vao thanh sau cua xoang nieu due. C. La mang dac du'oc tao thanh tai chd noi nay va sau do duo'c tai tao ong. D. Cac te bao vay tu xoang nieu due xam lan ong Muller, chap vao va thay the bieu mo tru cho tdi tan bieu mo phia ngoai cd tu' cung. II. Mo hoc A. Hieu mo: bieu md va\ lat tang khong sung hoa gom ldp be mat. ldp trung gian. ldp can day va ldp te bao day; dap ling vdi hormon. B. L d p duoi niem: la to chuc d em . xo. m a c h m au lone leo. doi khi co te bao dem hinh sao hoac hinh da dien k h o n g die n IVinh. 35 C. Ldp co: cac bo co' iron trong vong. ngoai doc. [3. Chi so trudng thanh: ti le phan tram te bao Can day Trung gian Nong Kin sinh 0 95 5 Tie nho 80 20 0 Rung tiling 0 40 60 Thai nghen 0 95 5 Sau de 100 0 0 Man kinh 100 0 0 III. Cac ton thuong viem A. Viem am dao thong thudng • Trichomonas vaginalis - Dieu tri: Metronidazole • Monilia: Benh nam Candida - Dieu tn: Imidazoles • Gardnerella vaginalis - Dieu tri: Metronidazole, clindamycin. • Actmoimces israelii - Dieu tri: I h a o d u n g cu trong buoiig tiicunu (1UD). B. Herpes • Hinh anh te bao va nuoi cay giong nhu d am ho • Dieu tri: Aeyclovir. C. Viem am dao kin thung • Nhieu nang nho duo'c lot bang su' tap hop cac te bao khong 16 chua di vat. • Khong co vi khuain dac hieu, nhung thuong ket hop chat che vo'i Trichomonas. • Gap o' phu nu co thai va 6 ngu'di suy tim • Tdn thu'ong se mat sau dieu tri trichomonas. D. Viem am dao sau man kinh hoac sau de • Am dao mong: Chav mau. bong rop, giao hop dau • Mo hoc: Bieu mo mong khong co su trudng thanh be mat bieu mo, viem khong dac hieu tai mo dem. • Dieu tri: Estrogen. E. Viem am dao do lau cau • Am dao do, mem kem theo tiet dich mu • Chan doan bang nuoi cay hoac tun acid nhan. • 6 tie em hoac be gai trudc day thi: Nhiem khuan dai dang • Lira chon dieu tri: Ceftriaxone. F. Viem am dao di \a t • Thudng gap d tie em • Ngu'di lan: Con sot nut gac G. Viem am dao troc vay • Khi' lur mii am dao nhieu • Am dao udt: te bao can day, bach cau da nhan trung tinh • Hiem va khd dieu tri • Thudng kern theo vdi liken phang d am dao hoac o mieng. • Dieu tri: Corticosteroid. Clindamycin. H. (Jiang mai • Sang giang mai duo'c chain doan bang kinh hien vi nen den. sinh thiet, va nhudm dac biet. Hiem gap d am dao. I. Mo hat • Thudng gap tai dinh vom am dao, sau cat tir cung • Can phan biet vo'i sa vdi trung sau cat tu' cung. J. Loet do tampon • Thuong kem theo vdi sir dung nut gac sieu tham • Dai the: Niem mac do hoac loet. • Vi the: Bieu mo bi loet. thay the bang to mo hat. Cd the thay di vat tren mau sinh thiet. • Dieu tri: khong doi hoi. Loet se lien sau khi ngirng sir dung tampon. • Cd the lien quan tdi hoi chung sdc nhiem doc ga\ ra do tu can vang. IV. Cac u lanh tinh A. Nang ong Gartner • La phan con lai cua ong Wolf • Gap o' vi tri thanh truo'c ben am dao. • Vi the: Du'oc lot boi mot lop bieu mb don. tru thap. Thuong gap di san vay. • Dieu tri: Phau thuat neu nang Ion. B. Nang vui am dao • Gap b thanh sau hoac thanh ben am dao • Bieu mb am dao do bi vui trong qua trinh phau thuat. • Vi the1: Nang duo'c lot bang bieu mb vay • Dieu tri: Phau thuat neu nang Ion. C. Nang nhav • La phan con lai do xoang true trang va xoang nieu due tach khong hoan toan tu nep nieu true trang. • Dieu tri: PhAu thuat neu nang Ion. D. Lae noi mac tir cung • Vi tri thuong gap: Tui cung sau am dao. • Vi the: Cac tuyen noi mac tir cung va dem bao. • Dieu tri: Phau thuat neu tbn thuong Ion. E. Benh u tuyen • Benh nhan thirong than phien tiet dich nhay qua nhieu. • Do bieu mo vav am dao khong thay the het bieu mo inj eb nguon goc ong Muller. • Dai the: Mang dang hat do. khong bat mau lOt hoac soi cb tu cung bat tlurbng. th u o n g tai 1/3 tren am dao. va a thanh tru'dc. • Vi the: Cac tuyen bieu mb hinh tru. che nhay tuong tu nhu tuyen cb trong; doi khi cac te bao cb long chuyen mau sam hoac sang giong nhir bieu mb noi mac tir cung hoac vdi tnrng (20% mau benh pham). Cac dam u tuyen cb the cb di san \a\ (nhu b cb tu cung). tang sinh vi tuyen (vdi thuoc tranh than, hoac hien tuong Arias-Stella. • Dang vdi trirng-noi mac tir cung cua benh u tuven thudng xuat hien cung vdi ung thu' bieu mo te bao sang. • Trong so nhung benh nhan pho'i nhiem tir trong tu cung vai di'ethx Istilbestrol (DES) trong 8 tuan dau sau thu thai. 90^ cb u tuyen; trong so nhung benh nhan pho'i nhidm sau 16 tuan. 10f< cb u tuyen. • Tlurbng kem theo vo'i ton thu'o'ng dang sin mao ngang hoac mao dong tarn a am dao. hoac vdi siii mao ga cd tu cuns. • Kha nang phat trien ung thir it (0.14/1000 toi 1.4/1000 tie nir pho'i nhiem vo'i DES). • Benh u tuven thudng gap. 40% benh nhan du'oc mo tu thi cd ton thuong nay mac dii khong cb bat thirong tren dai the nhung phat hien thay ton thirong khi cat am dao hang loat (Sandberg). • Dieu tri: Khong 40 • Theo doi benh nhan bang xet nghiem Pap va soi co tir cung hang nam. F. U loi am dao • Ton thirong giong hinh xup-lo do viriit u nhu o' ngudi (HPV). • Dieu tri: Boi acid trichloracetic, 5 - fluorouracil tai cho. G. U c o tr o n • La u hiem, xuat hien dang cuc duoi niem mac am dao. • Vi the: Gom cac bo te bao co tron hinh thoi ben xoan vao nhau. • Dieu tri: Ph£u thuat neu u Ion H. Polip am dao • Dai the: La ton thuong loi ra hinh ngon tay, co the co mot hoac nhieu polip. • Vi the’: Mo dem long leo. phu vdi cac te bao khong di£n hinh co the giong vdi sacdm dang chum nho (nhung lop trong khong tang sinh te bao). • Ditki tri: Cat u tai chd. I. Sa voi trung • Bien chung hiem gap sau phau thuat duong bung va duong am dao. • Dai the: Khoi chav mau nho tai dinh am ho, sinh thiet dau • Vi the: Niem mac vdi tning vdi te bao viem trong mo dem. • Dieu tri: Cat bo 41 V. Cac benh ac tmh A. Ung thu bieu mo tai cho (VAIN,) • Thuong khong co trieu chung, ket hop vdi HPV 16. duoc phat hien bang te bao hoc thudng qui. • Dai the: la cac 6 hong san, tang sung, mau trang, cac ion thuong da 6 tai 1/3 tren am dao. • Vi the: Roi loan thuan thuc te bao trong toan bo be da\ bieu mo (cac te bao khong trudng thanh, mat cuc tmh. ti le nhan/nguyen sinh chat tang, hinh nhan chia bat thudng). • Dieu tri: Cat rong tai chd, bdi kem 5FU (2% hoac 5r/c). dot laser. B. U ng t h u bieu m o te bao vay x a m lan am dao • Chiem tir 1 %-2% tdng so benh ac tinh phu khoa. • La loai ung thu am dao thudng gap nhat: 75% den 909c. • Vi tri thudng gap: 1/3 tren thanh trudc va sau am dao. • Trieu chung: Ra mau va khi hu am dao. • Lan tran theo dudngbach huyet - 2/3 tren am dao: Hach chau (giong n h u cd tucung) - 1/3 dudi am dao: Hach ben va hach dui (giong nhu am hoi • Phan giai doan FIGO - Giai doan 0: Noi bieu mo - Giai doan I: Khu tru a thanh am dao - Giai doan II: Td chut dudi am dao - Giai doan III: Lan long tdi thanh chau -G ia i doan IV: Lan qua khoi khung chau thuc thu. vao bang quang hoac true trang. • Giai doan IVa: Xam lan co quan ke can • Giai doan IV b : Di can tdi cac co quan xa. • Neu u ton thuong am dao va co tu cung, duoc phan loai la ung thu' cd tu cung nguyen phat. . Dai the: Cac tdn thuong dang loet hoac dang cuc • Vi the: Cac te bao vay ac tmh vdi cac mire do thuan thuc khac nhau (biet hoa cao va biet hoa thap. • Dieu tri: Xa tri la chit yeu (xa tri ngoai va dat ngudn radium). Phau thuat (cat tu cung triet can, cat am dao, va vet hach chau) chi trong mot so chon loc nguoi benh. • Song them 5 nam: Cho giai doan I: 94%: giai doan II: 80% giai doan III: giai doan IV: 0%. C. Ung thu bieu mo te bao sang am dao • Hiem gap. Benh nhan tie (7-29 tudi), me cd su'dung DES trong qua trinh mang thai (500 trudng hop ung thu bieu mo te bao sang cua am dao va co tir cung da duo'c bao cao cho toi nam 1986). • Ti le mac ung thu la 1/1000 tdi 1/10.000 phu nir pho'i nhiem vdi DES. • Tudi nl;ic *v n *1 lrun~ binh tai thd'i diem chan doan: 19 tudi. • 11 ieu cluing: Chay mau bat thudng hoac khi hu. • Dai the: U tai c6 tir cung (40%) hoac tai thanh trudc 2/3 tren am dao (60%) cac ton thirong co dang not duoi niem mac hoac hinh khoi sin nho nhu hoa sup lo'. • Vi the: Cac ong va nang duo'c lot bang te bao sang va te bao hobnail, hoac cac dam te bao sang. Dang ong nhu duoc coi la loai ac tmh nhat. • Dieu tri: Phau thuat (cat triet can am dao va tu cung. vet hach chau) hoac xa tri. • Song them 5 nam toan bo: 80%. D.U hac to • Hiem gap. Chu yeu 6 1/3 dudi va thanh trudc am dao. • Thuong gap dang cuc, da hinh thai nhan va te bao ro. • Tien luong xau (song them toan bo, 17%) vl chain doan thuong muon (mure 111). E. Sacdm xo hoac sacom co' tron • Hiem gap. nhung la loai u trung mo ac tinh nhat cua am dao. • Trieu chung: Khoi u to chay mau tai am dao. • Dai the: La khoi don doc tai thanh trudc ben am dao • Vi the: Cac te bao co' tron ac tinh vdi > 5 nhan chia/10 HPF. te' bao bat thudng ro (Tavassoli va Norris). • Benh nhan > 50 tuoi: Benh tien trien nhanh hon. • Dieu tri: Cat u tai cho F Sacom dang chum nho 44 • Hiem gap. Thirong xay ra o' tie gai dudi 5 tuoi. • Trieu chung: Chay mau va kin hu am dao. • Dai the: U mau do xam dang polyp, phu lap day am dao. • Vi the: Mo dem phu nd manh, cac te bao u hinh thoi dung thanh dam dac (nguyen bao co van) du'di bieu mo (ldp ao trong cua Nicholson). Cd the chain doan nham vdi polip lanh tmh. • Dieu tri: Cat toan bo u toan bo u sau do dieu tri hoa chat bci tra (Vincristine. Actinomycin D. va Cyclophosphamide [VAC]: hoac VAC va Adriamycin) co the xa tri hoac khong. • Song them 3 nam 78% (Copeland va cong sir). G. U xoang noi bi • Rat hiem gap. Xay ra d tie so' sinh va tie dudi 3 tuoi. • Dai the giong vdi sacdm dang chum nho • Vi the: Giong vdi u x^ang noi bi d budng trung: mang ludi hoc hoa long leo va cac the Schiller-Duval. • Di6u tri: Phau thuat va dieu tri hoa chat (VAC). Tien luong duoc cai thien bang dieu tri hoa chat. • Song them 3 nam: 84r ; . H I ng thu bieu mo di can • Co tir cung. noi mac tircung • True trang. bang quang • Ung thir nguyen bao nuoi - Dai the: Cue chay mau mau xanh den - Vi the: To ehi/c la nuoi (nguyen bao nuoi va hop bao nuoi). - Dit:u tri: Dieu tri hoa chat (80% chira khoi). 46 4. Co tuT cung I. Bao thai hoc II. M o hoc - Di san vay - Te bao bong khong dien hinh III. Cac thay deli tai c6 tir cung trong thai ky thai nghen IV. Nhiem trung V. Cac ton thirong lanh tinh VI. Cac u ac tmh I. Bao thai hoc A. C6 tir cung co nguon goc trung bi B. La ket qua cua sir ket hop phan giCra cua cac ong Muller C. Trung mo lan can tao mo dem va soi co D. Bieu mo vay lat tang cua c6 ngoai la ket qua cua sir chuyen dang bieu mo tru lot ong Muller E. Phan tiep gian giira bieu mo vay va bieu mo tru goi la vung chuyen tiep. II. Mo hoc - Di san vay - Tebao bong khong dien hinh A. Co ngoai: Bieu mo vay lat tang khong sirng hoa (ngoai tru' c6 tir cung bi sa) cau tao gom cac to bao nong be mat. te bao trunc sum \ a cac te bao can day. B. Co trong: La mot lop bieu mo tru don. cau tao gom cac te bao ti n. che nhay xep thang goc. nhan nam sat day. Cac te bao "dir tru" pliia du'Oi bieu mo tru. 47 C. M o dem: Cac te bao hinh thoi vdi phan urng mang rung trong thoi ky thai nghen; chua ( l r/r) di tich dang nang cua cac ong trung than (co the co kieu tuyen). D. Di san vay • Bi£u mo tuyen che nhay cua c6 trong duoc thay the bang bieu mo vay lat tang. • D ac trung bo'i sir tang sinh va di san cua cac te bao du tru' hoac chira biet hoa nam phia dudi lop bi£u mo tru. Cac te bao nay xep tang va biet hoa. thay the lap bieu mo tru nam phta tren, sau do thay the no bang ldp bieu mo vay. • T ao thanh mot kieu tai vung chuyen tiep cua co tu cu n g (vung T), cung la vi tri nguon goc cua ung thir te bao vay c6 tir cung. E. Te bao bong khong dien hinh • Gap d u loi c6 tu' cung, co the la kieu nhu (kinh dieni. phang, hoac vui vao trong tai co tu' cung. • Cau tao gom cac te bao nhan tang sic, khong deu. nhan dong, doi khi hai nhan. bao tuong co khoang sang quanh nhan ("te bao bong” ). • La chi diem cua nhiem \ init u nhu; cd the xac dinh bang plurong phap lai. • Cd the gap cac ton thu'ong u noi bieu mo cd tir cung (CINi • Di£u tri: Tuy theo muc do loan san. III. Cac thay doi tai co tu cung thoi ky thai nghen A. Co ngoai 48 • Tang do day, c ic bat thudng te bao tai ldp day goi y t6n thirong loan san. • Cac thay doi nay thoai trien sau khi mang thai va c^n danh gia can than tranh chan doan nham. B. Co trong • Tang sinh tuyen: Tang so luong tuyen kieu u tuyen va tang hoat dong che tiet. • Tang sinh bieu mo tuyen: Xep chong len nhau 2 den 3 lop. • Di san vay va dang nhay • Phan ung Arias-Stella: Cac te bao vdi nhan tang sac goi y benh ac tinh; khong cd hoat dong gian phan. C. M o dem: Tang mach mau (tao thanh vien quanh cac dong mach nho). phu, tham nhiem bach cau (50%), phan ung mang rung (10%). IV. NhiSm trung A. Viem co tu cung man • Dai the: C6 tir cung Ion ra ngoai. xung huyet va niem mac phu. cd cac nang Naboth. • Vi the: Tham nhiem viem dudi bieu mo (tuong bao. bach cau da nhan. bach cau don nhan). thudng duoc chain doan. • Dieu tri: Khong doi hoi phai dilu tri. B. Viem lao co tir cung • Hiem gap. thudng thu phat sau viem noi mac va \6i tnine do lao hoac lao ket hop. T4-LSPK 49 • Dai the: Ton thuong loet hoac phi dai giong ung thu bieu mo • Vi the: Cac cu lao dien hinh vdi te bao lympho, te bao dang bieu mo. te bao khong 16, va chat hoai tu ba dau tai trung tarn: xac dinh true khuan cu the. • Ditiu tri: Cac thuoc chong lao. C. Nhiem naim A ctinom yces • Gay ra bdi A c ti n o m y c e s Israelii, m ot loai ky khi gram duong. • Co lien quan vdi dat dung cu buong tu cung (IUD). • Vi the: G6m cac hat cau tao bdi cac soi phan nhanh. bat mau gram duong, cac choi xep hinh hang dau d ngoai vi, duoc xac dinh bang nhuom bac. • Di6u tri: Penicillin D. U loi co tir cung • Dai the: Cac t6n thuong mun com nam tai am ho hoac t6n thuong san va dat (mun com phang) d6 thay khi nhuom acid acetic. • Vi the: Ton thuong u nhu, can sung hoac tang sung, te bao bong, tham nhi£m viem trong mo dem. • Dieu tri: Acid trichloracetic, Imiquimod, dot dien. laser. E. H e rp e s • Dai the: La cac vet loet nho, nong. Benh nhan thudng co cac ton thuong herpes dau tai am ho. 50 • Vi the: Te bao vay nhi£u nhan vdi cac the vui virut ira acid hinh kmh m o trong nhan te bao. • Dieu tri: Acyclovir, Famcyclovir. F. C hlam ydia trachom atis • Viem cd tir cung nhay mil (dich xuat tiet xanh-vang) • Thuong kern theo vdi viem nang c6 tir cung • Duoc chan doan bang cay khuain • Di6u tri: Tetracycline, Doxycycline, Erythromycin G. Lau cau khuan • Lau cau Neisseria gonorrhea gay viem noi cci trong tir cung cap • Chain doan bang nuoi vi khuain • Dieu tri: Ceftriaxone tiem bap hoac Cefixime hoac Ciprofloxacin uong. V. Cac ton thuong lanh tmh A. Polip co tu cung • Dai the: La sir tang sinh khu tru cua niem mac cd tir cung mau do tuoi. nhieu mach mau, to chirc miin va cd cuong. • Vi the: Polip duoc lot bdi ldp bieu mo co trong hoac bieu mo vay lat tang: mo dem long leo. phu va tham nhiem viem. • Lam sang: Chav mau do giau mach mau va nhiem khuain. gionsz nhir ung thu cd tir cung giai doan sdm. • Hiem khi trd thanh ac tinh (0.2%-0.4%). • Can phan biet vdi ung thu c6 tu cung dang polyp (cuong khong bi xam lan bdi to chuc u trong trudng hop ung thu xuai phat tu polyp; tien luong tot). • Dieu tri; Cat tdn thuong xet nghiem mo benh hoc. B. N ang N aboth • La nang nhay u dong do bieu mo vay che phu cac khe tuyen cd trong. • Kich thudc thay doi (3mm tdi 3 cm), duoc lot bang bieu m o det hoac bieiu mo tru. • Nhln chung khong co trieu chung, khong ain phai dieu tn. C. Lac noi m ac tir cung • Dai the: La not hoi xanh • Vi th£: Cac tuyen noi mac tir cung vdi mo dem • Dieu tri: Sinh thiet chain doan. D. U ca tron • Vung sau cd tir cung • Vi the: Cac bo te bao co tron dan xen • Dieu tri: Git u co' hoac c k tir cung vi thudng co u ca tran cd tir cung va than tir cung ket hop. E. U tuyen hoac nang do di tich cua ong trung than • Duoc lot bang bieu mo tru thap hoac bieu mo vuong • Co the' nham vdi ung thu bieu mo tuyen • Dieu tri: Cat u neu u Ion. F. T ang sinh vi tuyen (tang sinh vi nang dang nhay) • Giong nhu polip lden 2 cm. • Xay ra trong khi su dung thuoc tranh thai duong uong (OCA), hoac dieu tri Estrogen keo dai, hoac trong thoi ky thai nghen. • Co the nham vdi ung thu bieu mo tuyen. • Vi the: Tang sinh phuc tap cac tuyen nho xep sat nhau duoc lot bdi cac te bao bieu mo det hoac bieu mo vuong khong co nhan bat thudng; co su tham nhiem dang nhay va viem man tai mo dem. • Di£u tri: Khong can thiet. G. U tuyen • Hinh mao ga, hinh vong hoac gia polip c6 tu cung. • Gap d con cua ba me sir dung DES. • Thudng gap Ion niem mac va di san vay c6 tu cung. • Vi the: Tuong tu nhu u tuyen am dao. • Dieu tri: Khong doi hot VI. Cac u ac tmh A. Cac thay doi ac tinh tai co tu cung: II noi bieu mo co tu cung (CIN) (RM Richart). • Cac ldp bieu mo sap xep Ion xon va mat cuc tinh. • Bat thuc san te bao; mat sir thuan thuc b'inh thudng. simg hoa trong cac ldp sau. cac te bao can day d ldp cao hon. hinh anh nhan quai va nhan chia bat thudng. • CIN I (loan san nhe): Cac te bao u co vdi hinh nhan chia lan tdi 1/3 chi£u day bieu mo • CIN 2 (loan san vita): Bat thudng te bao lan tdi 2/3 chieu day bieu mo • CIN 3 (loan san nang va ung thu tai ch6): Cac bat thirong te bao lan tdi tren 2/3 chieu day bieu mo. • Thai gian chuyen tiep trung b'inh tir CIN 1 va CIN 2 thanh CIN 3 la xap xi 5.8 nam va 3.1 nam. Thai gian tien trien trung binh tir CIN 3 thanh ung thu bieu mo xam lan la 10 nam (RM Richart va BA Barron). • Di£u tri: Dot lanh. dot dien. cat laser, hoac khoet chop, sau do soi co tir cung va nao ong c6 tir cung. B. He thong Bethesda (1991) cho phien do Pap • Cac bat thudng te bao vay - ASCUS (cac te bao vay khong die-n hinh co y nghla khong xac dinh) phan ung hoac ung thu. Quan ly theo doi: • Hoac la soi co tir cung, sinh thiet (BX), nao ong co tir cung (ECC) chi doi vdi cac u ASCUS • Hoac la dieu tn viem. teo cho tat ca benh nhan. Lam lai phien do Pap sau 3 thang. 54 • Neu ket qua Pap nhac lai la ASCUS hoac LSIL: Soi co tu cung, BX, ECC. • Neu ket qua Pap nhac lai am tinh: Lam lai xet nghiem Pap 6 thang/lan x 3 lan. - LSIL (ton thuong noi bieu mo vay do thap): N hilm HPV va loan san nhe Quan ly theo doi: • Hoac la soi cd tu cung, BX, ECC tat ca benh nhan • Hoac la dieu tri viem, teo, lam lai xet nghiem Pap sau 3 thang. • Neu ket qua lam lai van la LSIL: Soi co tir cung, BX, ECC. • Neu am tinh: Lam xet nghiem Pap cu 6 thang/lan x 3 lan. - HSIL (tdn thuong noi bieu mo vay do cao): CIN 2, CIN 3. Quan ly theo doi: Soi cd tir cung. BX, ECC. - Ung thu bieu m o te bao vay Quan lv theo doi: • Soi co tir cung, BX. ECC • Neu ket qua mo hoc khong khang dinh ung thu bieu mo te bao vav: khoet chop co tu cung, hoac LEEP (ky thuat cat dien vong). • Cac bat thudng te bao tuyen - A GUS (cac te bao tuyen khong dien hinh y nghla. khong xac dinh) phan ung hoac ung thu. Quan ly theo doi: . Soi co tu cung, BX. ECC 55 . Sinh thiet noi mac tir cung neu AGUS gai y ung thu hoac neu benh nhan > 40 tudi. Can nho rang AGUS cung co thd phat hien duoc nhieu trudng hop loan san vay. - Ung thu bi^u mo tuyen Quan ly theo doi: • Soi cd tir cung, BX, ECC va sinh thiet noi mac tu cung . Neu mo hoc klwng khang dinh ung thif hieu mo tuyen hoac cac benh ly ac tinh khac: Can tien hanh cac thu thuat khac: khoet chop cd tu cung, sieu am vung tieu khung, C A - 125. • Quan ly nhung trudng hap xet nghiem Pap bat thuong trong khi thai nghen - Soi cd tu cung, BX, khong nao ong cd tu cung neu phat hien ASCUS 2 lan , LSIL 2 lan, HSIL, AGUS. - Theo doi bang xet nghiem Pap 3 thang/lan - Soi co tu cung nhac lai trong trudng hop xet nghiem Pap tien trien - Xet nghiem Pap 8 tuan sau de . Neu Pap bat thudng: Soi cd tu cung • Neu Pap binh thudng: Nhac lai trong 6 thang. • Phuong phap xet nghiem dong thoi HPV va Pap van con dang trong giai doan nghien cuu. Gia tri du doan duong tinh ve tinh trang tien ung thu cua xet nghiem HPV mdi la 20%. va gia tri du doan am tmh la 99% vdi xet nghiem Pap la 56 ASCUS (Digene HC). Doi vdi nhung ngudi duoc chain doan LSIL, xet nghiem HPV duong tinh trong mot so luong Ion trudng hop (83%). C. Ung thu bieu mo te bao vay vi xam lan (xem hinh) Cac quan niem khac nhau ve ung thu bieu mo vi xam Ian co tir cung. 1) GOG: 3 mm hoac it han tu mang day mat bieu mo hoac mo tuyen (ranh trong co tir cung) (FIGO giai doan la,: be rong <7mm); 2) FIGO giai doan la2: 5mm do sau xam lan tCr mang day den mang day mat bieu mo hoac bieu mo “tuyen" va be rong < 7mm. • Chiem 4% tdng so ton thuong CIN • Nen do do sau xam lan mo dem tren benh phaim khoet chop cd tu cung hoac benh phaim cat tir cung. • Do sau xam lan mo dem: 3 mm (GOG) hoac 5 mm (FIGO) tmh tir mang day; khong co sir tap trung cac 6 xam lan khong thong noi va khong co sir xam lan mach bach huyet. • Dinh nghla mdi cua FIGO bd sung them do rong xam lan 7 mm theo bi ngang. • Do ludng duoc tinh tir mang day cua bieu mo phu lan can hoac tir bieu mo “tuyen” . • Di can hach: Dudi 1 mm la 0,4%; 1,1 den 3 mm la 1.3r/c 3,1 den 5 mm la 6,8%. • Cac te bao ung thu xam lan sdm co bao tuong rong, ua acid do su co mat cua cac soi actin va myosin (cac protein co nit). • Dieu tri: Khoet chop, vdi dien cat sach te bao ung thu o benh nhan tre hoac cat tu cung toan bo (chi ap dung vdi dinh nghla cua GOG ung thu vi xam lan 3 mm khong co sir xam lan mach bach huyet). D. Cac loai ung thu co tir cung • Ung thu bie'U mo te bao vay - Chiem phan ldn cac benh ac tinh c6 tir cung (90%). - D a i the: Co the la the siii. loet, hoac tham nhidm (ton thuong sui co the tao hinh thiing trong ong c6 tir cung). - Xay ra d vung bien doi (hoac ch6 noi vay tru) - Cac vi tri: Moi trudc va moi sau (60%-70%) - Phan giai doan FIGO • Giai doan 0: Ung thir noi bi£u mo (CIS) • Giai doan I: Ung thir khu tru hoan toan tai c6 tir cung - Giai doan la\ Ung thu xam lan mo dem sdm, chi duoc chan doan bang vi the (tat ca cac tc>n thuong dai the dSu duoc phan thanh giai doan lb) Giai doan la,: Xam lan to chuc dem vi the khong qua 3 mm va khong rong qua 7mm. Giai doan Ia2: Do sau xam lan < 5 mm, lan tran theo be ngang < 7 mm. - Giai doan Ilr. Tat ca cac.-tdn thuong khac Ion hon Ia2, bat ke co quan sat duoc tren lam sang hay khong. - Giai doan lb,: T6n thuong < 4 cm - Giai doan Ib2: Ton thuo'ng > 4 cm • Giai doan II: T6n thuong lan rong khoi c6 tir cung nhung chua xam lan toi thanh chau. Co the t6n thuong 2/3 tren am dao, nhung chua tdn thuong 1/3 dudi. - Giai doan 11 a: 1 on thuong am dao nhung tdn thuong mo can tu cung khong ro rang. - Giai doan I Ilr. Ton thuong mo can tir cung (parametre) ro rang. • Giai doan III: Co the xam lan ra tdi thanh chau; ton thuong 1/3 dudi am dao. - Giai doan Ilia : Chua xam lan tdi thanh chau; t6n thuong 1 /3 dudi am dao - Giai doan Illb: Xam I an tdi thanh chau; than u nude hoac than mat chuc nang. 59 • Giai doan IV: Xam lan ra ngoai dudng sinh due. T6n thuang niem mac bang quang hoac true trang, di can xa. -G iai doan iVa: T6n thuong co quan lan can (niem mac bang quang hoac true trang) - Giai doan IV b: Di can xa - Phan loai mo hoc dua tren muc do biet hoa u. • Biet hoa cao, biet hoa vua (thudng gap nhat), va biet hoa thaip. • Sung hoa te bao Ion, khong sung hoa te bao Ion (tien luong tot nhat), va khong sung hoa te bao nho (tien luong xau nhat) (JW Reagan va AB Ng). - Vi the: Cac dai, dam te bao ung thu noi thong nhau hoac dung thanh dam dac tham nhiSm mo dem. • Biet hoa cao (do I): Sung hoa nhieu (hat cudm keratin); cac te bao trudng thanh va co kich thuoc ldn, nhan tang sac: cau noi lien bao ro; hoat dong gian phan tdi thieu; co su tham nhiem te bao viem man tfnh vao mo dem va doi khi ca te bao khong 16 loai vat la. • Biet hoa vua (do II): Cac te bao u da hinh thai hon vai nhan ldn. khong deu, va bao tuong it hon. Khong co cudm keratin. Hoat dong gian phan nhieu hon. • Biet hoa kern (do III): Cac te bao co nhan hinh Ovan tang sac va bao tuong hep ranh gidi khong ro. Doi khi te bao ldn da hinh vdi nhan quai va hinh nhan chia bat thudng. - Tien luong phu thuoc vao giai doan lam sang, do sau xam lan, co mat hay khong su xam lan mach mau, kich thudc u. va tinh trang hach bach huyet. 60 - Ung thir hieu mo co tir cung lan tran bang cach xam lan rong tai ch6 va lan tran theo dudng hach huyet. - Lan tran theo duong bach huyet: Tdi hach canh c6 tir cung. hach ha vi, hach chau ngoai, hach trudc xuong cung. va hach chang hai tai dong mach chau goc. hach ben va hach canh dong mach chii. • Ton thuong hach: Giai doan I: 15%; giai doan II: 30%; giai doan III: 50%. - Trieu chung lam sang: Ra mau sau giao hop, khi hu hoi dich mau. - Dieu tri: • Giai doan Ia2: Cat tu cung triet can va vet hach chau hoac xa tri. • Giai doan lb va Ila: Cat tu cung triet can va vet hach chau hoac xa tri (ton thuong hinh thiing: Xa tri va cat tir cung ngoai can). • Giai doan lib. III. IV: Xa tri hoac xa tri -hoa chat (cisplatin) - Song them 5 nam: Giai doan I 85%; giai doan II 60%; giai doan III 35%; giai doan I \ 15%. - Tai phat trong vong 2 nam sau dieu tri. Trong so nhung benh nhan chet vi ung thuco tucung. 85% chet trong vong 3 nam. • Ung thu' bieu mo te bao nhu vay (te bao chuyen tiep) - La bien the hiem gap cua ung thu co tir cung te bao vay - Vi the;: Cau true nhu vai cac nhu duoc boc boi mot so lap te bao dang te bao day bat thuang. Sinh thiet nong co the nham vai u loi bat thuang. D uac chain doan bang sinh thiet khoet chop. - Dac diem lam sang va di£u tri tuong tu nhu ung thu bieu mo te bao vay. - Tai phat co the muon (7 nam). • Ung thu bieu mo the: san - T6n thuong hiem gap tuong tu nhu ung thu dang mun com cua am ho - U xam lan tang truong chain co xu huang tai phat tai ch6, khong di can. - Vi the’: U co dang ve lanh tmh, cac te bao vay chen ep to chuc dem - Dieu tri: Cat tu cung don thuan. • Ung thu bieu mo tuyen - Chiem 5% tbng so ung thu bieu m o co tu cung. Gan day. ti le co tang do giam ung thu bieu mo vay hoac tang ung thu bidu mo tuyen? - Dai the: Ton thuong dang nhu hoac dang loet tai ong co tu cung hoac tai vung co ngoai: u to co the xam lan vao ong co tu cung (ton thuang hinh thung). - Ung thu bieu mo tuyen tai ch6: C h in doan bang benh phaim khoet chop co tu cung hoac cat tu cung- cac tuyen cb trong 62 b'inh thirong ket hop vdi Cac t u y e n ung thu. cac te bao mat cuc tinh, to va nhan tang sac, va hinh nhan chia. Khong co phan ung cua mo dem. Co the nham vdi viem. phan ung Arias-Stella. va tang sinh vi tuyen. Thudng ket hop vdi ung thu tai chd dang thuong bi. - Dieu tri: Cat tu cung don thuan hoac khoet chop c6 tu cung tdi dien cat am tmh. - U ng thu bieu m o tuyen vi xam lan khong phai la chan doan cd the chap nhan. - U ng thu bit;u m o tuyen xam ia'n sdm (hoac ung thu bieu mo tuyen nong) • Khai niem duoc E. Burghart dua ra. • The tich u < 500 m m ': Khong di can hach va khong tai phat. La yeu to tien luong tot hon la do sau xam lan. • Dieu tri: Cat tu cung don thuan. - Ung thu bieu m o tuyen c 6 trong • Cac tuven xep sat nhau. it mo dem, cac te bao co ti le nhan/nguyen sinh chat tang. . Chiem 70% tiSng so ung thu bieu mo tuyen c6 tu cung. . Do mo hoc - Do 1: Biet hoa cao - Dp 2: Biet hoa vua (thudng gap nhat) - Do 3: Kern biet hoa. 63 - TPn thuang rat biet hoa duac goi la u tuyen ac tinh hay ung thu bi^u mo tuyen vai su bien doi toi thieiu, tdn thuang hiem gap, kho nhan biet, va thuong kern theo hoi chung Peutz-Jeghers. Mo hoc lanh nhung tien luong xau. . Neu noi mac tu cung bi tdn thuong, duoc coi la ung thu noi mac tu' cung xam lan co tu cung (FIGO). • Kieu di can tuong tu' nhu' ung thu bieu mo vay cP tu cung. tuy nhien xam lan tai cho va di can hach co ve sdm han. • Di£u tri: Tuong tir nhu ung thu bieu mo vay c6 tu cung. • Song them toan bp thap hon ung thu bieu mo vay co tu cung (giai doan I, 75%; giai doan II, 50%; giai doan III. 8%: va giai doan IV, 0%). - Ung thu bieu mo tuyen co tu cung dang noi mac tu cung • Chiem 20% cac ung thu bieu mo tuyen c6 tu cung • Kho phan biet vdi ung thu bieu m o tuyen noi mac tu cung xam lan co tu cung. • Cac te bao va tuyen giong vdi ung thu noi mac tu cung dien hinh. • Thudng la tdn thuang biet hoa cao. • Song them tot hon ung thu loai co trong. - Ung thu bieu mo tuyen te bao sang • Chiem 3% cac ung thu bieu mo tuyen co tu cung. • Phan ldn cac khoi u xay ra d benh nhan cd me su dung DES trong thoi ky mang thai (ti le mac la 0.14-1,4/1000). 64 •Doi khi xuat phat tir vet tfch trung than tai c6 tu cung va vom am dao. •Dai the: Dang I6i hoac dang loet. • Vi the: Cac te bao sang va cac te bao dang dinh dau to vdi cau true tuyen kieu nhu noi tuyen, ong tuyen nho hoac cac day tuyen dac. • Dieu tri: Cat tu cung triet can va cat am dao hoac xa tri. • Song them giai doan I 90%. Co the tai phat trong vong 3 nam sau diSu tri. - Ung thu bieu mo tuyen nhu tuyen co long chuyen • Ung thu bieu mo tuyen biet hoa cao xay ra d benh nhan tre • Vi the: Nhu mong lot bdi cac te bao tru tang cd nhan bat thudng va ft hinh anh gian phan. Nhi£u te bao viem trong true lien ket xo' trung tam. • Tien luong tot hon • Dieu tri: Sinh thiet khoet chop vdi dien cat khong con te bao ung thu hoac cat tir cung don thuan. • Ung thu' bieu mo tuyen-vay (hon hop) - La su' pha tron giua ung tlur bieu mo vay va tuyen. - Thudnc gap d phu nu cd thai, hiem khi phat hien d giai doan sdm, tuong ung vdi nhieu tdn thu'ong hinh thung. - M uc do ac tfnh nhieu hon cac hien the ung thu bieu mo vay khac. - Thudng di can xa (phdi. xuong) T5-LSPK 65 • Ung thu bieu mo te bao kmh (Glucksmann va Cherry . 1956). - La bieu hien dang kern biet hoa cua ung thu bieu mo tuyen-vay. - Hiem gap. chiem 1,2c/c tdng so ung thu cd tu cung - Cau tao g6m cac dai cac te bao bieu mo ac tinh xam lan n^m trong td chuc dem thua. . Cac te bao Ion, da dien hoac hinh ovan, va thanh te bao ro net, bao tuong hinh kinh m d hoac cac hat min; nhan noi ro: chat nhishn sac phan tan min; hat nhan ro; nhi£u hinh anh gian phan. . Mo dem gom cac vach xo' mong, tham nhiem nhieu te bao viem (bach cau ua acid, te bao limpho, tuong bao). - Di can hach sdm - Dap ung kem vdi xa tri va phAu thuat. E. Cac ung thu nguyen phat hiem gap khac • Sacom - Sacom co' tron: Chain doan nhu sacom co tron tu cung. dua tren cac hinh anh gian phan tren 10 vi trudng (HPF). - Sacom md dem: Ton thu'ong be mat. duoc di£u tri bang cat tu cung don thuan. - Sacdm dang chum nho: Giong tdn thuong d am dao - U trung bi hon hop: Giong vdi thanh phan tuong ung c day : Co su' thay doi bat thudng cua bieu mo. va mo dem. cac thanh phan hon tap (sun. cac te bao co van). • Ung thu bieu te bao day dang tuyen 66 - Ton thirong it gap: Benh nhan d do turn 60 hoac 70. xay ra 6 ph;1n co tir cung, thirong kern theo vdi ung thu bieu md vay tai chd. - Giong vdi u te bao day cua da: G6m cac 6 te bao hinh tron hoac hinh ovan dong nhat. nhan d£u. sAm mau, sap xep hinh hang dau d ngoai vi 6 te bao u. - Xam lan tai ch6 - Dieu tri: Cat tu cung don thuan • Ung thu bieu md dang tuyen nang - Hau het xay ra o' phu nu gia. ngu'di da den, de nhieu. - Giong nhu u tuyen nude hot - X am lan tai cho va di can muon - Vi the’: Cac 6 hoac cac dai te bao noi thong vdi nhau gom cac te bao tron hoac hinh ovan dong nhat vdi bao tuong hep va nhan tang sac. Cac the hyaline trong 6 te bao u. - Di<§u tri: Giong nhu' dieu tri ung thu bieu mo vay c6 tu' cung. • Ung thu bieu mo te bao nho (u than kinh noi tiet. te bao yen mach) - La loai rat ac tinh - Vi the: Cac dai te bao nho, tron don thuan co ti le nhan/niiuyen sinh chat cao. nhuom hoa mo mien dich duo'ng tinh x di NSE vii chromogranine. Tren hien vi dien tu cho thay cac hat tiet than kmh. - Tien luong cuc k\ \au. 67 - Dieu tri tirang tu nhu ung thu bieiu mo te bao nho cua ph6i: Cdt tu cung triet can va vet hach chau sau do di£u tri hoa chat va xa tri. F. Ung thu di can co tu cung • Tu ung thu bieu mo tuyen noi mac tir cung, ung thu bieu mo am dao, va ung thu bieu mo bu6ng trung. • Ung thu bidu mo rau • Ung thu bieu mo tuyen vu • Ung thu bieu mo da day • Benh bach cau. 68 5. Noi mac tuT cung I- Bao thai hoc II. Mo hoc III. Cac thay doi sinh ly IV. Cac thay doi do thav thuoc gay ra V. Cac benh viem VI. Cac u lanh: Polip noi mac tir cung VII. Qua san VIII. Ung thu' bieu mo IX. Cac di can u den noi mac tir cung I. Bao thai hoc A. Than tir cung bat nguon tir sir hoa phan duoi cua cac ong Muller (uterovaginal primordium) B. Long ong duoc lot bo'i bieu md tru tir do sinh san cac tuyen noi mac tu' cung. C. Cac tuyen noi mac tir cung thuc day sir tao thanh mo dem va co tron tir to chuc trung mo lan can. D. BiC'u mo. mo dem va co tron la nhurng thanh phan co nguon goc tu trung bi. II. Md hoc binh thudng A. Tuyen noi mac tu cung • Bieu mo cau tao gom cac te bao tru cao vdi nhan dai nam v. - POD 1 1: Mo tien mang rung dudi bieu md be mat. co hoat dong gian phan trong md dem. - POD 12: Cac dai dac mo tien mang rung, tham nhiem te bao hat vao mo dem. - POD I 3: Tham nhiem te bao hat m d dem id net. - POD 14: Hoai tu va chay mau dang o trong mo dem. - Kinli nguyet: La manh vun mo dem vdi cac soi thrombin, xuat huyet va dut gay tuyen. - D in h ngay can dua tren vung bieu hien sdm nhat d giai doan 48 gid (\T du POD 9-10). Phai co khong bao dudi nhan trong it nhat la 50% tuyen chuc nang de khang dinh co su' rung trung. - Suy pha hoang the: Gap khoang 3-5% so ngudi vo sinh. Co bieu hien che tiet b'inh thudng. tuy nhien dinh ngay mo hoc c h a m hon 2 ngay so vdi ngay chu ky kinh nguyet (tuong quan vdi ngay bat dau hanh kinh). Di£u tri bang Progesterone dat am dao, Clomiphen citrate, hoac hormon hudng sinh due man kinh d ngudi. B. Thai nghen • Tuyen bieu hien sir tang tiet va phan ung Arias-Stella, cau tao gom cac bui hoac cac nhu bieu mo tuyen, te bao ldn bao tuong sang hoac co cac khong bao. nhan bat thudng nhe (ldn. tang sic. noi hat nhan va doi khi co bieu hien gian phan). Co the nham vdi ung thu bieu mb tuven te bao sang. • Te bao dem trd thanh te bao rung: La nhung te bao ldn hinh da dien. cb vung bao tuong rong quanh nhan. sap xep theo kieu kham. 73 C. Man kinh • Bieu mo be mat mong, te bao hinh tru thap. • Bieu mo tuyen tru thap khong hoat dong. Cac tuyen thua. thinh thoang co cac nang (teo nang). • Mo dem xo. IV. Cac thay doi do thay thuoc gay ra A. Dung cu trong buong tu cung (IUD) • Viem man tmh tai cho hoac lan rong, bieu mo b& mat co di san vay timg ci. • N h iim Actinomyces (Actinomyces israelii, la loai ky khi gram duong) • Ap-xe voi - buong trung mot ben co the la sau viem noi mac tu cung. • IUD vdi Progesterone: Phan ung mang rung va teo tuyen tai be mat noi mac tu'cung. • Xuat hien te bao bat thudng tren xet nghiem Pap. B. Sudung thuoc tranh thai dudng uong (OCA) • Cac tuyen thang. khong hoat dong, khong bieu hien gian phan hoac che tiet. 74 • M o dem vdi su' thay d6i gia mang rung, cac tieu tinh mach noi ro, cac limphd bao va bach cau da nhan phan bo rai rac (mat can bang tuyen mo dem) C. Progestin: Phan ung mang rung va uc che tuyen. D. C lom iphen: Giong vdi chu ky kinh nguyet binh th udng. T ro n g m ot so n g h ie n cuu cho thay cd sir giam ti le tuyen/mo dem. E. Chat tuong tu Gn-RH • Noi mac tir cung mong, khong hoat dong (teo noi mac tir cung) • So luong tuyen giam • Mo dem dac. F. Dieu tri thay the horm on (HRT) • Ket hop giu'a estrogen va progestogen. • Thudng gap noi mac tir cung khong hoat dong. G. Dieu tri Tam oxifen • Duoc dung d benh nhan ung thu vii. • Tang do day niem mac tir cung, xuat hien cac polip ldn (9 cm), ung thu' noi mac tir cung. 15 V. Cac benh viem A. Viem noi mac tir cung cap • Nguyen nhan: Nhiem khuain thoi ky sinh de (lien can kx khi, E. coli. Bacteroides, Pseudom onas, va han huu gap trudng hop nhiem khuain Clostridium perfringens). lau cSu. nam (IL'D) hoac Chlamydia trachomatis. • Dai the: Xung huyet. phu va sung noi mac tu cung nhe. be mat m u n g mu co cac vet loet dan g virut. tham nhiem to chuc co tu cu n g va q u a n h tu' cu n g , viem tac tinh mach tu cung va mach chau. • Vi the: Tham nhiem lan toa mo dem bach c&u da nhan: tap trung bach cau trong long tuyen, xung huyet mach mau va phu mo dem. • Dieu tri: Khang sinh. B. Viem noi mac tu cung man tinh • Nguyen nhan: H jD . con sot md thai nghen (mang rung kinh hoa. rau thai ma). lao. u eo dudi niem. • Dai the: Noi mac tu cung nhat nhat, va sung. 76 • Vi the: Viem man. tham nhilm cac te bao tron va tuong bao (te bao limpho va cac nang limpho binh thirong xuat hien trong noi mac tir cung): phu mo dem va xung huyet mach mau. • Di£u tri: Theo nguyen nhan C. Viem lao noi mac tu cung • Thu phat do lao voi trung. • Vi the: Cu lao vo'i te bao kh6ng lo va te bao dang bieu mo. hiem khi co chat hoai tu' ba dau. • Chain doan xac dinh: Xac dinh vi khuan khang con-toan. D. Viem noi mac tu cung sau man kinh • G ap o' phu nu sau man kinh. co the gay chav mau • Vi the: Noi mac tir cung khong hoat dong. mong. mach mau thanh mong va voi hoa: tham nhiem te bao limpho va tuong bao vao m o dem: di san vay thanh tu'ng 6 tren bieu mo be mat (benh vay ca tir cung. neu ton thuong rong). VI. Cac u lanh tmh: Polip noi mac tu cung \. Cau tao gom cac to chirc nho ra tir noi mac tir cung vao buong tu cung. B. Lam sang: Hau het khong co trieu chung lam sang, co the co chay mau do polip loet Ion hoac co cuong nho vao co tir cung hoac am dao. C. Vi the: Bieu mo phu 6 3 phia, loi la td churc dem \ o vdi mach mau thanh day. Co 3 loai polip noi mac tu cung • Polip tren noi mac tir cung chuc nang: Co kieu binh thudng giong nhu noi mac tu' cung xung quanh. • Polip tren noi mac tir cung chua thuan thuc: Co kieu tang sinh hoac teo • Polip tuyen-co: G6m cac thanh phan noi mac tir cung va \6 mo co tron. D. Thoai trien ac tinh thap (0.45% - 3,7%) (chu veu can xet n g h ie m phan day polip n h a m chain d o a n phan biet giura thoai trien ac tinh cua polip hay ung thu' bi£u mo tu\en dang polip). E. Gap a phu nu sau man kinh, 15% benh ac tinh noi mac tir cung la kern theo vdi polip lanh tinh noi mac tu cung (Peterson va Novak). Tien hanh nao toan bo tir cung hoac soi buong tir cung sinh thiet khi ket qua la polip noi mac tu cung lanh tinh d phu nu cha\ mau sau man kinh. F. Dieu tri: Cat dudi hudng dan cua soi buong tu cung. 78 VII. Qua san A. Djnh nghla: Tang sinh cac tuyen va mo dem do sir dung Estrogen kich thfch noi mac tir cung keo dai. B. Dai the: Noi mac tir cung day, mupt. mau vaiig kem. doi khi co kieu polip. Do day noi mac do dupe len tdi 5 mm. C. Cac tip qua san: Don gian, phuc tap. bat thudng • Qua san don gian - Ti le tuyen/mo dem nghieng ve phia tuyen - Cau true tuyen khong d£u co the tirng o hoac lan toa. - Tuyen gian. khong deu, co it dam dac - Te bao tuyen bi keo dai va phan tang vdi nhan lech thang goc v i phia mang day. - Co cac hinh anh gian phan nhung khong nhieu. - Khong co bat thudng te bao - Ti le chuven dang ac tmh thap. dudi 1% (RJ Kurman). • Qua san phuc tap - Ti le tuyen/mo dem tang nhung mo dem noi mac tir cung con ton tai giu'a cac tuven. - Cau true tuyen phuc tap ro ret - Cac tu y e n k h o n g deu, bieu mo l6i ra, tao nhu hoac gap nep va tao thanh dam dac cac te bao bieu mo tuyen tifa sat lung vao nhau. - Cac te bao trong tuyen bi keo dai, phan tang nhan. kich thudc va hinh dang dong deu, cuc tmh te bao binh thuang. - Hinh anh gian phan thay dcii khac nhau. - Khong gap hinh anh te bao bat thuang. - Ti le chuyen dang ac tinh 3% (RJ Kurman). • Qua san bat thuang - Qua san tuyen co cac te bao bat thudng. - Ti le tuyen/mo dem > 1 giua cac tuyen con mo dem - Bat thudng te bao co the la: • Nhe: Mat cuc tinh te bao, bao tuong rong ua acid, nhan tron, chat nhiem sac min va phan tan deu. • Nang: Nhan ldn. da hinh thai, chat nhiem sic phan tan khong deu. von cuc, hat nhan n6i ro. - Qua san bat thudng co the la: . Bat thudng don gian: Cac tuyen co te bao bat thudng nhung khong phuc tap ve cau true. • Bat thudng phuc tap: Cau true tuyen phurc tap. te bao bat thuong. 80