NH NGHA

Cn c gi l UT ph qun (Bronchogenic carcinoma),

do u c khuynh hng phn ln t cc t bo tuyn hoc tit nhy ca lng ph qun phi

DCH T
Nhng nm u 1900, UT phi cn rt t, t l ng th hai sau ung th tuyn tin
lit (nam) v ung th v (n) Cui nhng nm 1900, UT phi l nguyn nhn hng u gy t vong Hoa K Gn y, vt qua c bnh tim mch c xem l nguyn nhn hng u gy t vong lin quan n ht thuc Nm 2006, c 174.470 trng hp mi ca bnh ung th phi v ph qun. 158.000 ca t vong M nhiu hn so vi ung th trc trng, ung th v, v ung th tuyn tin Hu ht cc ung th phi c chn on giai on tin trin, tin lng xu t triu chng hoc khng c triu chng cho n khi bnh tin trin nng thm

DCH T
Khong 7-10% bnh nhn ung th phi khng c triu chng, v bnh ch c
chn on tnh c sau khi chp X-quang ngc v mt l do khc. Ngoi ra, bnh thng c gim cn st nh. Hu ht cc bnh nhn b ung th phi c km ht thuc lm cho vic iu tr tch cc tr nn kh khn S cn thit chn on ung th phi giai on sm v c kh nng cha tr vn cha tht s hiu qu

DCH T HC
Chng tc: n ng da en c t l mc bnh v t vong cao nht trong
bnh ung th phi v ph qun Di truyn: Cc bt thng quan trng nht c pht hin l t bin lin

quan n gia nh ras ca oncogenes. Cc nghin cu ngi cho thy

rng ras kch hot gp phn vo s pht trin khi u nhng ngi b ung th phi. Ras t bin gen xy ra gn nh c quyn trong ung th tuyn

v c tm thy 30% nhng trng hp nh vy.

C CH BNH SINH
Ung th phi c khuynh hng pht trin phi P (khong 55% nhu m
phi phi P, v cy kh qun bn P) Ung th phi thng xy ra thy trn hn thy di, do c cung cp mu d dng t biu m ph qun, ng mch ph qun.

PHN LOI M HC
Ung th phi t bo nh (SCLC), thng cho di cn xng, gan, tuyn
thng thn, mng ngoi tim, no v ty sng Ung th phi t bo khng nh (NSCLC). (85% )
Ung th t bo tuyn (35-40%), sinh t cc tuyn nim mc ph qun, thng
xy ra ngoi phi Ung th biu m t bo vy (SCC) (25-30%), c tm thy trong trung tm

phi. Biu hin l tn thng lng ph qun. y l loi thng xuyn nht
lin quan vi chng tng calci huyt Ung th biu m t bo ln (10-15%), biu hin bi mt khi ngoi vi trn X

quang ngc

Ung th t bo tuyn
Dng ung th Phi thng thy gii N
Khi u ngoi vi phi Thng xm ln mng phi v hch trung tht

C th di cn t cc c quan khc trong c th

Thng t ghi nhn lin quan ti thuc l

Ung th biu m t bo vy

Thng xut hin Nam ln tui

Khi u mt nhnh ca ph qun Tn ti khu tr trong ngc lu hn cc dng UT phi khc trc khi c biu hin thc th

Khng c ghi nhn n khi c i cn sm Lin quan mnh ti tnh trng ht thuc l

Ung th biu m t bo ln
t khi no c bit ti, ch yu do chn on loi tr
C th xut hin bt c vng no ca phi Thng u rt ln thi im pht hin

Thng gy di cn trung tht v no

Ung th t bo nh
Cn c gi l t bo Oat
Pht trin t t bo ni tit *kulchitisky cells+ ni nhiu hormones c tit ra
Cho di cn hch hoc cc c quan khc nhanh hn cc nhm khc

YU T NGUY C
Thuc l (85-90%)
78% (Nam); 90% (N) Khi thuc l cha hn 300 cht c hi vi t nht 40 cht c bit n nh

cht gy ung th
Khng phi tt c ngi ht thuc l u pht trin thnh ung th phi v khng phi tt c bnh nhn ung th phi c tin s ht thuc

Cht c hi (10-15%)

(Radon(10%), asbestos, arsenic, chromium, nickel, aming, Halogen

ether, ng v phng x, bc x ion ha, vinyl clorua).

Hydrocacbon v nitrosamine

c bit l gy bin i DNA

YU T NGUY C
Mi trng nhim (1-2%)

Ngoi ra, t cc bnh phi khng c tnh nh bnh phi tc nghn mn tnh, x ho phiv cn, v bnh lao c chng minh l c lin quan vi t l ung th phi tng ln Tin s gia nh: gp khong 80% trng hp nu gia nh c ngi b UT phi

Yu t lin quan (RR) tng ln 10-22 ln

S iu trong ngy
Thi gian s dng Thay i nguy c ty theo thi quen ht

Peto et al, BMJ 2000

LM SNG
HO (80%)
Thng l du hiu sm nht m c, i khi c m (NT)

HO MU (70%)
Cn phn bit vi mu t ng tiu ha, thng m s ln vi mu Hay gp nhng BN c ht thuc l

KH TH (60%)
- Do s tc nghn mt nhnh ph qun ln hoc tnh trng trn dch mng phi

AU NGC KIU MNG PHI

Do khi u n lan vo mng phi, hoc tnh trng nhim trng phi-mng phi ti pht nhiu ln

HI CHNG TIN UNG TH

Tng trng
St cn Mt mi

Ni tit
Hi chng Cushing do bi tit ni tit v thng thn
Tit hormone chng bi niu khng thch hp gy h natri mu Hi chng Carcinoid Tng calci huyt

Him khi, h ng huyt

Xng
Clubbing, 10% n 20% Osteoarthropathy 5%

HI CHNG TIN UNG TH

Thn kinh c (15% v ph bin nht vi ung th biu
m t bo nh)
Vim a c Hi chng ging nhc c (Eaton-Lambert)

Thn kinh ngoi vi

Thoi ha bn cp tiu no
Bnh no

Huyt khi tnh mch

au d di, lan vng vai nch cnh tay pha mt tr

Teo c cnh tay, bn tay Horner syndrome (ptosis, miosis, hemianhidrosis, enophthalmos) Ph n do chn p mch mu

MARKER TRONG TM SOT UNG TH PHI

Neuron specific enolase (NSE)
nhy, c hiu tuy khng mch s dng trong sng lc, NSE c s dng nh mt s tr gip trong chn on ung th phi t bo nh Nng huyt thanh ca NSE (> 100 mg / L) BN c nghi ng bnh c tnh SCLC vi xc sut cao Chn on phn bit vi cc khi u khc cng c kh nng lm tng nng NSE trong mu nh u thn kinh, ung th gan, u lympho v seminoma NSE tng va cn c thy nhng bnh nhn vi bnh phi lnh tnh, tuyn ty, d dy,

i trc trng v ung th v

Gi tr tin lng ca NSE c chng minh cho thy kh nng theo di sau iu tr SCLC, cng nh pht hin SCLC ti pht sau khi iu tr

MARKER TRONG TM SOT UNG TH PHI

Carcinoembryonic khng nguyn (CEA)
CEA tng cao trong ung th phi dng tuyn t bo ln Tuy nhin, nng cao cng c tm thy trong cc bnh lnh tnh khc v trong

cc khi u c tnh khc

CEA hu ch trong chn on phn bit bnh ung th phi t bo khng nh, tt nht l kt hp vi CYFRA 21-1 CEA cung cp thng tin tin lng trong NSCLC, c bit l adenocarcinoma Ngoi ra, CEA c vai tr quan trng trong trong vic gim st iu tr gim st giai on tin tin bnh v pht hin ti pht

MARKER TRONG TM SOT UNG TH PHI

Cytokeratin-19 phn mnh (CYFRA 21-1)
CYFRA 21-1 nhy vi NSCLC, c bit u t bo vy. CYPRA21-1 cao trong cc ung th tit niu, tiu ha v bnh ung th ph khoa. Tuy nhin, c ch trong chn on phn bit cc trng hp ung th phi nghi ng, c bit nu sinh thit

khng th thc hin.

CYFRA 21-1 l mt yu t tin lng c lp trong c hai giai on u v cui ca NSCLC. Cc bo co khc c ngh CYFRA 21-1 cng c th c tin lng gi tr trong SCLC. CYFRA 21-1 c tim nng ng k iu tr gim st NSCLC bnh cng nh pht hin

bnh ti pht sau khi chnh iu tr, c bit trong ung th phi t bo vy.
Bo co gn y cho thy rng trong nhng bnh nhn vi giai on tin tin ca NSCLC tri qua ha tr liu, cc xu hng trong CYFRA 21-1 trong giai on iu tr ban u d on p ng vi iu tr tip theo.

MARKER TRONG TM SOT UNG TH PHI

Progastrin-releasing peptid -(ProGRP)
ProGRP l du hiu ng tin cy cho SCLC (c hiu tt v nhy 73-76%) Khng s dng trong kim tra do him khi tng cao trong cc khi u c tnh Nng ProGRP > 200 ng/L nghi ng ung th phi, v nng > 300 ng/L thng c ghi nhn SCLC (nu khng c suy chc nng thn) ProGRP hu ch trong chn on phn bit, c bit trong vic phn bit SCLC. c s dng nh mt du hiu duy nht, v tt hn trong khi kt hp NSE cung cp

thng tin b sung.

Mt s nghin cu cho thy n c th theo di SCLC hoc pht hin bnh ti pht sau iu tr.

MARKER TRONG TM SOT UNG TH PHI

Squamous cell carcinoma antige (SCCA)
Mc d t nhy trong NSCLC hn CYFRA 21-1, v khng thch hp s dng trong vic kim tra, SCCA c c hiu cao i vi ung th t bo vy Tuy nhin, SCCA c th tng ln trong cc u biu m vy ca c t cung, thc qun, c, u v phi, cng nh trong bnh v da SCCA c th c dng trong chn on phn bit NSCLC, c bit i vi ung th t bo vy, tt nht l kt hp vi CEA v CYFRA 21-1.

Vai tr ca Markers khi u pht hin sm ung th phi

Nng cao ca CEA, CYFRA 21-1, NSE, SCCA, v ProGRP gi bnh c tnh Adenocarcinoma CEA Ung th biu m t bo vy CYFRA 21-1 v SCC Ung th t bo ln CYFRA 21-1 v NSE Ung th phi t bo nh NSE v ProGRP

HNH NH HC
X quang ngc tiu chun
X quang ngc tiu chun (CXRs) c th o kch thc ca khi u phi, c bit l cc tn thng ngoi vi

CXRs c th cho ta bit tnh trng trn dch mng phi, hoc du hiu
hy xng sn thnh ngc hoc t sng hoc hch trung tht

X quang ngc tiu chun km so vi chp CT trong vic pht hin cc di cn hch trung tht, nhy ch 10-30%, c hiu 90%, cao hn so vi CT

HNH NH HC
CT Scan ngc c cn quang
CT Scan ngc v bng c cn quang nhm kho st thm c gan v tuyn thng thn CT Scan nhm nh gi tnh trng xm ln trung tht, dch mch mu ln hoc ph qun trung tht Tiu chun CT Scan resectability bao gm:
Khong cch gia khi u v trung tht < 3cm Khi u bao quanh M ch < 90

Xut hin lp m bao quanh gia khi u v trung tht

HNH NH HC
CT Scan ngc c cn quang
Tiu chun CT Scan nonresectability bao gm:
C nh hng n gc Carina Khi u bao quanh hoc tip gip ng mch ch, ln cn bn phi hoc bn tri ng mch phi, hoc bao quanh thc qun hn 180

Vi lt ct mng 5mm, s hin din ca lp m trong trung tht, v tnh mch, nhy v c hiu ca CT trong vic pht hin cc hch trung tht khc nhau ng k, vi khong 40-84% v 52-80%, tng ng. S thay i ny phn nh bin i interobserver v s khc bit trong tiu chun nh gi kch thc ca hch bt

thng. Gi tr tin on (+)ca CT l khong 85%.

HNH NH HC
Cng hng t
MRI c s dng thay cho CT trong trng hp bnh nhn c phn ng vi cht cn quang hay suy thn nng Khng c s khc bit gia MRI v CT, nhy ca CT l 63%, v MRI l 56%. Phn bit khi u T3 v T4 ca CT l 84%, v MRI l 80%

HNH NH HC
PET CT
Vai tr ca PET ph bin k t th k 21, c ch nh trong vic nh gi nhng u phi khng xc nh bn cht Qut PET ton b c th l chnh xc hn qut CT lng ngc, hoc no, x hnh xng, hoc MRI PET vt tri so vi CT trong vic nh gi s khc bit gia cc khi u c tnh v lnh tnh PET vt tri so vi CT trong vic nh gi di cn hch trung tht. nhng bnh nhn vi N2, PET c nhy 83% v c hiu 94%, so vi nhy 63% v c hiu 73% vi CT. Kh nng vt tri ca PET l nh gi dc cc hch hilar, c nhy 73% v c hiu 76%, so vi mt nhy 18% v c hiu 86% vi CT

HNH NH HC
PET CT
FDG-PET scan c gi tr tin lng v lin h cht ch vi t l sng cn bnh nhn tri qua iu tr ung th phi FDG PET (+) c tin lng ti t hn ng k hn so vi bnh nhn c kt qu (-) S kt hp ca CT v PET ci thin vic x tr

CC XT NGHIM KHC
SOI M TM T BO C TNH:
Rt c gi tr cc cc th UT t bo vy, ung th t bo nh NI SOI PH QUN:

C gi tr tin on cao (90%, nu kt hp chi ra TB hoc sinh thit)

SIU M: Kho st tnh trng di cn gan

X HNH XNG SINH THIT TY XNG

Kho st tnh trng di cn xng

HNG DI CN
Di cn gan v tuyn thng thn
CT scan ngc m rng xung gan v tuyn thng thn, c nhy khong 85% trong vic pht hin di cn gan. T l tng t vi MRI v siu m Siu m vt tri so vi CT trong phn bit u nang gan Di cn tuyn thng thn thng gp v thng n c. Cn phn bit vi u tuyn thng thn. Tn thng < 1cm thng lnh tnh, di cn thng > 3cm PET ton b c th c th s lm gim s lng sinh thit tuyn thng thn c thc hin cho cc tn thng thng thn khng xc nh

HNG DI CN
No di cn
SCLC v ung th dng tuyn thng cho di cn no CT scan c cn quang thng cho thy di cn no bn cu no tri MRI vt tri so vi CT trong kho st vng h sau v vng tip gip vi nn s

Tuy nhin, kho st hnh nh b no khng c ch nh rng ri nu

bnh NSCLC khng c triu chng v t l mc ca di cn no khong 2-4%

HNG DI CN
Di cn xng
X hnh xng bng Technetium-99m (99m Tc) c ch nh trong cc bnh nhn b au xng hoc au khu tr. nhy 95% nhng t l dng tnh gi kh cao nhng bnh c km thoi ha v chn thng xng Thng nh gi tnh trng di cn xng sn th hai v th chn bn phi Di cn ct sng c th gy chn p ty sng, v c khong 5% di cn xng c

pht hin bng x hnh xng khi khng c triu chng

X hnh xng trc phu thut khng phi l ch nh thng qui

HNG DI CN
Di cn phi
Di cn phi trong NSCLC rt thng gp, khong 20% khi tin hnh khm nghim t thi

Di cn phi t ung th ph qun ch yu thy di phi tri

Chn on trc phu thut u nh phi trn CT thng rt kh v khng th phn bit gia granulomata v nt x

GIAI ON UNG TH

GIAI ON UNG TH v PHU THUT

Giai on I v II: khi u nm hon ton trong phi v c th
ct b hon ton bng phu thut Giai on IIIA v IIIB: khi u pht trin ra khi phm vi phi, c di cn n cc hch bch huyt trung tht cng bn (N2) (giai on IIIA) hoc n cu trc trung tht (T4 N0 M0). Giai

on ny c th tin hnh phu thut ct b ton b phi

km bc ton b hch trung tht Giai on IV: c di cn v khng cn ch nh phu thut

GIAI ON UNG TH v PHU THUT

D c phu thut hay khng th t l sng 5 nm
giai on 1: 65% giai on 2: 40% giai on 3: 15% giai on 4: 05%

Tuy nhin, t l pht hin bnh sm giai on 1 v 2 l rt thp (16%)

IU TR
La chn iu tr: (1) phu thut giai on bnh cn khu tr, (2) ha tr
vi giai on bnh c di cn, v (3) x tr kim sot khi ung th cn khu tr nhng bnh nhn khng th phu thut.

Kt hp a tr liu (phu thut, ha tr v x tr) c th cung cp kt qu

sng cn tt hn n tr liu Phu thut khng phi l iu tr chnh cho ung th t bo nh

IU TR
Ung th giai on u (I v II) c th ch cn phu thut ct thy hoc/c km no
hch Giai on IIB (T3 N0 M0), thng l cc trng hp c dnh thnh ngc, vic phu thut ct thy n thun t t l sng cn 5 nm (36%); ct thy km no hch (50%) Cc trng hp IB-IIB ct thy km ho tr b tr

NGUY C PHU THUT

Nguy c phu thut thng gy ra do gy m ton thn ko di hoc phu thut gy
tn thng cc cu trc, nhu m phi cn li. Nhng nguy c c ghi nhn: Chy mu, mu ng Vim phi, Nhim trng Xp phi (trn kh mng phi) Tn thng cc c quan ln cn nh tim, Lon nhp tim nhp tim

R kh- ph qun
au ngc sau phu thut Kh th

PHU THUT
Ct thy phi:
L phng php thng dng nht trong phu thut ung th phi kt hp vi no hch vng. Thng phng php ny t ra vi bnh nhn c chc nng phi b suy gim v c nhng bnh nhn ln tui Nguy c t vong l 3-6%

PHU THUT
Ct ton b phi :
L phng php ch c ra khi ct thy phi khng loi b c ton b khi u hoc khi hch di cn n vng trung tm. Thng ch c

ch nh nhng bnh cn tr, chc nng tim phi cn tt

Nguy c t vong l 7-28%

PHU THUT
Ct mt phn thy phi:
L phng php phu thut ch ra mc ch ct u v t m phi xung quanh. Thng phng php ny ch nh cho cc trng hp bnh cao tui hoc chc nng phi km khng m bo c h hp. i vi u phi giai on T1N0M0 th y l phng php t ra kh hiu qu Ct phi dng Wedge : Mc ch ra l ct mt phn nh ca phi c cha u. Thng ch p dng khi bnh c qu nhiu nguy c

PHU THUT
Phu thut ni soi lng ngc (VATS)
c s dng loi b khi u nh gn b mt ca phi m khng cn m lng ngc. c coi l mt phng php h tr v khng ci thin thm v t l sng cn cho bnh.