NHN XT V C IM LM SNG, CN LM SNG V IU TR PHU THUT CA 249 TRNG HP UNG TH TUYN GIP TI BNH VIN NI TIT TRUNG NG

Trn Ngc Lng, Mai Vn Sm, Nguyn Tin Lng. Bnh vin Ni tit Trung ng.

Summary : The aim of this study was to review the clinical, paraclinical signs and outcome of patients undergone surgical treatement for thyroid cancer at Hospital of Endocrinology from January 2002 to June 2004.A retrospectve analysis was performed in 249 patients including 28 males and 221 females.Most age from 20 to 49 years old(71,9%), with primary surgery in 94,3%, immovable nodules in 6,0%, the pain sign in 3,6%,compressive sign in 18,6%,no patient with hoarseness of voice. There was only one of hypothyroidisme. The echography: single nodules in 57,7%, multiple nodules in 42,3%,solid nodules in 62,8%, complex nodules in 36,4%. The fine needle aspiration: thyroid cancer or suspicious for malignance in 63,5%. The histologic diagnosis composed of papillary carcinoma in 71,0%,follicular carcinoma in 23,0%, medullary in 2,7%,anaplastic in 3,6% and lymphoma in 0,8%. Total thyroidectomy and total thyroidectomy associated with cervical nodes dissection were the most common procedure in about 67,8%. There were 71% of the tumuor limited to the thyroid gland,9,3% muscle invasion and 16,1% tracheal invasion. Morbidity included hemorrage in 0,4%,respiratory insufficiency in 5 cases (2%) with tracheotomy in 0,8% (2 cases), transient hypocalcaemia in 7,7%, transient hoarseness of voice in 11,4%, permanent hypocalcaemia in 0,4%.

Mortality in 2 patients (0,4%) due to respiratory insufficiency and circulatory faillure. The author found that the clinical presentation of thyroid cancer is not usually acute, the paraclinical signs are not specific. The fine needle aspiration plays an important role to do the diagnosis. To avoid the severe morbiditys and comlplications,it is necessary to do early the diagnsois and the surgical treatement. Tm tt Cc tc gi nghin cu lm sng, cn lm sng v phu thut ca 249 bnh nhn ung th tuyn gip (UTTG) c phu thut ti Khoa ngoi - Bnh vin Ni tit Trung ng t thng 1 nm 2002 n thng 6 nm 2004. T l nam/n l 28/221=1/7, vi tui ch yu t 20 n 49 tui: 179 bnh nhn (71,9%), thi gian pht hin bnh <1 nm 118 BN (49%), ch yu cha c iu tr g 160 bnh nhn (65,3%) v m ln u l 233BN (94,3%), bu I gp 145BN (58,7%), ch c 15BN u khng cn di ng khi thm khm. Cc du hiu au thy 9 bnh nhn (3,6%), chn p 46BN (18,6%), khng c BN no thay i ging ni. Ch c 1 BN trong tnh trng suy gip, cn li u bnh gip. Trn siu m c 142 trng hp n nhn (57,7%), 104 a nhn (42,3%), bu th c155 BN(62,8%), th hn hp 90 BN (36,4%). Chc t bo bng kim nh trc khi m chn on l UTTG hay nghi ng 158 bnh nhn (63,5%), p t bo

trong khi m dng tnh 67,7% s bnh nhn. M bnh hc c 176BN (71,0%) th nh, 57BN (23,0%) th nang, 5 BN(2,0%) th tu, khng bit ho 9BN (3,6%) v lymphoma l 2BN (0,8%). Phu thut ct ton b tuyn gip v ct ton b km no vt hch l ch yu 168BN (67,8%). Trong khi m thy 176 (71%) bu cn nm trong tuyn, 23BN (9,3%) u xm ln c, 40 BN (16,1%) u xm ln vo kh qun hay bao kh qun, c 2 trng hp u lan rng khp c. Sau m c 1 bnh nhn (0,4%) phi m li ngay do chy mu, 5 BN suy h hp cp trong c 2 BN phi m kh qun cp

cu, nut sc tm thi 5 BN (2,0%), ni khn tm thi 28 BN (11,4%), h canxi tm thi 19 BN (7,7%), h canxi vnh vin 1 BN (0,4%). T vong 2 BN sau m bu IV, khi m u xm ln ht vng c, cht do suy h hp cp v suy tim cp. Cc tc gi thy rng UTTG lm sng thng biu hin m , khng rm r, cc xt nghim cn lm sng thng khng c gi tr c hiu, chc t bo trc khi m rt quan trng hng ti chn on, vic chn on v phu thut sm rt quan trng trnh cc bin chng v di chng sau khi m.

1. T VN Ung th tuyn gip (UTTG) chim 1% cc loi ung th ni chung. Ti Vit Nam, H Ni ung th tuyn gip chim 2% tng s ung th trong nam gii 0,8%, n gii 3,6% (1). Ung th tuyn gip l loi t triu chng, triu chng khng rm r, ch yu l pht trin ti ch (12). Chnh v th nhiu bnh nhn thng n giai on mun. Vic iu tr UTTG l phu thut cng vi cc phng php h tr khc nh dng hormon tuyn gip c ch, x tr bng I131. C nhiu loi tn thng gii phu bnh l khc nhau ca UTTG, t loi rt c tnh nh ung th th khng bit ho n loi coi nh lnh tnh ca bit ho th nh. Cc phng php phu thut c p dng khc nhau v thi gian sng thm sau m cng khc nhau tu theo mi loi tn thng ny. ti ny nhm xem xt cc c im lm sng v cn lm sng ca UTTG ; ng thi nh gi cc tn thng gii phu bnh ca loi ung th ny v cc kt qu sm ca phu thut. 2. I TNG V PHNG PHP NGHIN CU. 2.1. i tng nghin cu. Bao gm tt c cc bnh nhn c chn on v c m do UTTG ti Khoa ngoi Bnh vin Ni tit Trung ng t 7 thng1 nm 2002 n 30 thng 6 nm2004. 2.2. Phng php nghin cu. Phng php nghin cu hi cu, tp hp h s ca tt c nhng bnh nhn c m v c kt qu cui cng l UTTG v phn tch cc thng s sau. 2.2.1. Cc du hiu lm sng trc m. - Xc nh tui, gii. - Thi gian pht hin bnh. - Cc hnh thc iu tr trc y. - Biu hin lm sng vi cc du hiu chn p nh kh th, kh nut, au - Thm khm lm sng vi v tr, ln ca bu, mt , di ng v hch c. 2.2.2. Cc du hiu cn lm sng trc m. - Hormon: Nng cc hormon FT4, TSH trong mu.

- Siu m tuyn gip: Xc nh v tr, s lng v tnh cht ca bu vi dng c, lng hay hn hp. - X hnh: Vi cc hnh thi nhn lnh, nhn m v nhn nng. - Chc t bo bng kim nh: Thc hin khoa t bo nhm xem xt s bnh nhn c chn on l ung th v khng c chn on l ung th trc m. 2.2.3. nh gi trong khi m. - nh gi ca phu thut vin v tnh trng ca u cn nm trong nhu m hay ra ngoi, tnh trng thm nhim vo cc c quan xung quanh, hch di cn. - p t bo: ngay sau khi ct, u c b i p vo lam knh nhum soi ti khoa chn on t bo t cho phng hng x tr tip theo. - Cc phu thut thc hin: ct bn phn,ct mt thu, ct ton b tuyn gip, ct ton b km theo no vt hch, ct mt phn tuyn gip trong nhng trng hp di cn rng khng th ct trit c 2.2.4. Din bin sau m. - Tnh trng chy mu sau m: phi can thip li hay khng - Suy h hp sau m: ch cn th oxy n thun hay phi m kh qun. - H canxi mu, ni khn. - Cc bin chng khc. 2.2.5. Kt qu gii phu bnh l: Bnh phm sau m c ngm vo dung dch formon v lm m bnh hc ti khoa chn on t bo. 2.3. X l s liu: Cc s liu c phn tch bng phn mm EPI INFO 6.0 3. KT QU. Bng 1. S phn b theo la tui La tui S bnh nhn < 20 tui 17 20-29 tui 63 30- 39 tui 62 40- 49 tui 54 50- 59 tui 31 60 - 69 tui 16 > 70 tui 6 Bng 2. S phn b v gii Gii S bnh nhn (249) Nam 28 N 221 Bng 3. Thi gian pht hin bnh Thi gian pht hin S bnh nhn (n=241) < 6 thng 61 6 thng 1 nm 57 2 5 nm 58 6 10 nm 16

T l % 6,8 25,3 24,9 21,7 12,4 6,4 2,4 T l % 11,2 88,8 T l % 25,3 23.7 24,1 6,6

>10 nm

49

20,3 T l % 65,3 30,2 2,4 2,0 T l % 94,3 4,5 1,2 T l % 7,7 51,0 27,9 10,1 3,2 T l % 39,9 31,7 23,8 3,6 di ng Di ng bt Khng d 233 15 94,0 au 9 3,6 Ging ni (n=248) Bnh thng Thay i 248 0 6,0

Bng 4. c iu tr trc Loi iu tr trc S bnh nhn (n=245) Cha iu tr g 160 Ung thuc n thun 74 Ung thuc+chc ht 6 p l 5 Bng 5. m c S ln m S bnh nhn (n=247) M ln u 233 M ln 2 11 M ln 3 3 Bng 6. ln ca bu ln ca bu Bu Ia Bu Ib Bu II Bu III Bu IV S bnh nhn (n=247) 19 126 69 25 8

Bng 7. V tr ca bu S bnh nhn (n=248) Thu bn phi 99 Thu bn tri 81 C 2 bn 59 Thu eo 9 Bng 8. Tnh cht ca bu S bnh nhn (n=248) T l % Mm 1 0,4 Mt Chc 225 90,7 Cng 22 8,8

Bng 9. Du hiu chn p, au (n=247) Chn p S bnh nhn 46 T l % 18,6 Bng 10. Tnh trng hch, ging ni Hch khm thy (n=248) Khng thy Khm thy S bnh nhn 228 20

T l %

91,9

8,1 Ln nht 26,1 9,8

100

0 Trung bnh 14,7 1,91

Bng 11. Nng hormon Nh nht FT4 (pmol/l) 4,0 TSH (mU/l) 1 Bng 12. c im siu m

S bnh nhn T l %

Tnh cht nhn (n=247) c Lng Hn hp 155 2 90 62,8 0,8 36,4

Slng nhn (n=246) n nhn a nhn 142 104 57,7 T l% 100 0 0 S bnh nhn 83 5 158 2 1 T l % 71,0 3,6 9,3 16,1 T l % 31,8 67,7 0,5 T l % 71,0 23,0 2,0 3,6 42,3

Bng 13. X hnh S bnh nhn(n=6) Nhn lnh 6 Nhn m 0 Nhn nng 0 Bng 14. Chc t bo (n=249) T l % Loi t bo 33,3 Bu nhn 2,0 U tuyn 63,5 Ung th hay nghi ng 0,8 Khng xc nh c 0,4 Vim gip mn Bng 15. nh gi trong khi m (n=248) S bnh nhn U cn trong tuyn 176 U xm ln ht vng c 2 U xm ln ra c 23 U xm ln vo kh qun 40 Bng 16. p t bo trong khi m (n=217) Loi t bo S bnh nhn Bu nhn 69 Carcinoma 147 Khng xc nh 1 Bng 17. Kt qu m bnh hc (n=249) S bnh nhn Ung th th nh 176 Ung th th nang 57 Ung th th tu 5 Th khng bit ho 9

Loi khc

0,8 T l % 36,3 14,9 T l % 26,2 2,4 34,3 33,5 1,2 0,8 0,4 1,6 T l% 0,4 1,2 0,8 2,0 11,4 0 7,7 0,4 0,8

Bng 18. Tnh trng hch (n = 248) S bnh nhn Thy trong khi m 90 Di cn vi th 37 Bng 19. Cc phu thut thc hin (n = 249) S bnh nhn Ct 1 thu 65 Ct thu + eo 6 Ct ton b 85 Ct ton b + No hch 83 Ct 1 phn u 3 Ct gn ton b 2 Ct eo 1 Ct thu + ly nhn thu 4 Bng 20. Cc tai bin v bin chng Cc tai bin v bin chng Chy mu m li Suy h hp Khng m kh qun (n=248) M kh qun Nut sc tm thi (n=248) Ni khn Tm thi (n=246) Vnh vin H canxi mu Tm thi (n=246) Vnh vin T vong (n=249) S bnh nhn 1 3 2 5 28 0 19 1 2

4. BN LUN 4.1. c im lm sng Bnh gp ch yu ph n, vi t l Nam/N = 28/221 =1/7 v la tui t 20 n 39 tui(50,2%) Thi gian b bnh < 1 nm chim a s 118 bnh nhn (49,0%), ch yu cha c iu tr g (65,3%) v c 233 (94,3%) bnh nhn l m ln u. ln ca bu ph bin mc I(theo phn loi ca WHO) 145 bnh nhn(58,7%). Bnh vin Ni tit Trung ng l n v cui cng chuyn khm v iu tr bu c, Khoa ngoi li c ngay bnh vin, chnh v vy a s bnh nhn s c m lun khng phi chuyn vin hoc iu tr ni khoa lng vng trc khi n c c s iu tr ngoi khi bu c ch nh m. V tr ca nhn thy tng ng nhau gia bn phi, bn tri v c hai bn vi t l ln lt l 39,9%, 32,7%, 23,8%. Trn Minh c m 131 bnh nhn gia cc bn ln lt l: 42, 23 v 66 bnh nhn (2).Nh vy s lng bu c hai bn ca chng ti t hn ca Trn Minh c.

- Khi thm khm bu chc 225 bnh nhn chim 90,7% vi di ng bnh thng 233 bnh nhn(94,0%). Nut vng, kh nut, kh th ch gp 18,6% cc trng hp, thm khm thy hch vng c l 20 bnh nhn, c 9 bnh nhn au vng c nhng khng c bnh nhn no thay i ging ni. iu ny cho thy bnh nhn b UTTG rt d b b qua khi thm khm bu n thun bng lm sng. 4.2. c im cn lm sng - Ch c 1 bnh nhn trong tnh trng suy gip cn tt c bnh nhn u bnh gip vi nng trong mu trung bnh ca FT4 l 14,71 v ca TSH l 1,91 - Khng c s khc bit nhau gia n nhn v a nhn trn hnh nh siu m. n nhn l 142 bnh nhn, a nhn l 104 chim ln lt 57,7 % v 42,3% trong tng s bnh nhn.Trong nhn c chim ch yu 155 bnh nhn (62,8%) v nhn th hn hp l 89 bnh nhn (36,0%). Hch c ch pht hin c 15 bnh nhn (6,1%) khi lm siu m. Nh vy vi kt qu trn cho thy rt kh phn bit nhn lnh tnh v nhn ung th trn hnh nh siu m. - Chc t bo bng kim nh chn on ung th hay nghi ng c ung th gp 158 bnh nhn (63,5%) trong khi bu nhn lnh tnh l 83 bnh nhn (33,3%). c im ny cng gn vi thng bo ca Trn Minh c thng bo(2) vi chn on dng tnh l 83,2% 131 trng hp m ung th gip.V vi cc tc gi khc chn on dng tnh t 69% n 93% (6,12). Nhng p t bo trong khi m chn on dng tnh l ung th ln n 67,7%. Tuy khng c k thut ct lnh chn on tc th nhng p t bo cng gip cc phu thut vin a ra c phng php phu thut ngay trong m. Tt nhin khi quyt nh th cng cn phi da vo cc tn thng i th quan st c trong khi phu thut. 4.3. Kt qu phu thut 4.3.1. Tnh trng quan st c trong khi m. - C 176 bnh nhn (71,0%) u cn nm trong bao tuyn trong t chc theo Trn Minh c ch c 29,8% s ca l cha dnh vo m ln cn (2). S bnh nhn ca chng ti dnh vo bao kh qun li nhiu hn l 40 bnh nhn (16,1%) ca Trn Minh c l 5,3 %, s xm ln vo khi c vng c li tng ng nhau 9,3 % v 9,2% (2). Cc kinh nghim ca Mayo Clinic cho thy rng khi mt ung th th nh ra khi bao tuyn gip xm ln vo cc cu trc bn cnh th v tr b xm ln s nh hng n vic sng thm. S xm ln vo kh qun v thc qun th nh hng c ngha n vic sng thm trong khi th s xm ln vo c, thanh qun, dy qut ngc th nh hng c lp khng c ngha ti vic sng thm (7). - Trong khi m thy c 90 bnh nhn (36,3%) c hch dc c c n chm v h thng n, Trn Minh c gp 45,2% s bnh nhn (2). Trong s 90 bnh nhn ny ch c 37 bnh nhn (41,1%) c hch di cn khi lm m bnh hc.Theo cc tc gi th t l di cn hch c t 30% n 50% (12) i vi nhng bnh nhn trong khi m thy c hch th chng ti tin hnh ct ton b c no vt hch khoang trung tm hay c khoang bn v khoang trung tm. 4.3.2. Th m bnh hc. Ung th biu m th nh chim nhiu nht 176 bnh nhn (71,0%), th nang 57 bnh nhn (23%), th tu 5 (2,0%), th khng bit ho 9(3,6%) v loi lymphoma l 2 (0,8%). So snh vi cc tc gi khc thy nh sau: Th nh Th nang Th tu Th vy Lymphom Khng Tc gi S Bn-% S Bn-% S Bn-% S Bn-% a bit ho

T.M.c 82(62,6%) 26(19,8%) 7(5,3%) 3(2,3%) 0 13(9,9) (n=131) R.SIM 120(80,5% 22(14,8%) 4(2,7%) 0(0) 0 3(2,0%) (n=149) ) T.N.Ln 176(71,0% g 57(23%) 5(2,0%) 0(0%) 2(0,8%) 9(3,6%) ) (n=249) Trong cc th caUTTG th th nh v th nang l loi lnh tnh nht. Theo Mayo Clinic, qua 2 278 bnh nhn c m UTTG v theo di t 1940 n 1990 th t l sng thm l (7): S Bn - % Tui trung Thi gian sng thm (n = 2 278) bnh (nm) (%) M bnh hc 10 nm 20 nm Th nh 1851 (81%) 44,4 95,5 94,7 Th nang TB khng a axit 153(7%) 51,0 80,5 71,1 Th nang TB a axit 93(4%) 58,4 84,4 78,7 Th tu 181(8%) 41,4 82,9 79,7 Cn vi mt s tc gi khc th t l sng thm 10 nm i vi ung th th nh v th nang t 85 95% (6,11,12). Phu thut ch yu l ct ton b tuyn gip 85 bnh nhn (34,3%), ct ton b + no vt hch 83 bnh nhn (33,5%). Trong nhng trng hp khi m kim tra khng thy c hch th chng ti khng t vn no vt hch mt cch h thng, v nu no vt hch th s lm tng t l tn thng tuyn cn gip v dy thn kinh qut ngc, tr nhng trng hp ung th th tu hay ung th th khng bit ho chn on c trc khi m ; iu ny cng nh nhn xt ca cc tc gi khc(4,12). Trong nhng trng hp m u thm nhim nhiu vo kh qun khng th ct b hon ton c th chng ti ct gn nh hon ton ch li phn rt mng trn b mt ca kh qun nhm trnh cc bin chng nh phng php m Judith Czaja McCaffrey lm (shave excision) (9). Ct 1 thu n thun thc hin 65 bnh nhn (26,2%). l nhng trng hp trc khi m hoc p t bo chn on l bu nhn lnh tnh hoc l khi ung th rt b (<1cm ng knh), cha xm ln ra ngoi hay cha c hch. Theo Ashok R.Shaha th vic s dng thng qui ct ton b i vi UTTG bit ho l 1 iu nn trnh(5). Chng ti khng c trng hp no ct 1 thu v ct gn ton b 1 thu nh Trn Minh c thng bo (40,4%)(2), bi v nu li mt cht t tuyn gip th vn khng m bo chc nng m vn cn c nguy c ti pht. C 8 trng hp ct 1 thu ly nhn 1 thu, nhng trng hp ny cng khng chn on c ung th trc v trong khi m. Tt c nhng bnh nhn ny u t vn theo di sau m u n nh k. c bit c 3 trng hp chng ti ch ly b 1 phn t chc hoi t ca khi ung th, y l nhng bnh nhn c u ln, xm ln vo ton b cc c quan, b phn ca c thnh mt khi chc khng th ct b, ly phn hoi t gii phng tm thi chn p cho bnh nhn. Tt c cc trng hp sau m ct ton b tuyn gip do ung th u c gi i iu tr tip Iod phng x ti Qun Y vin 108. 4.4. Bin chng phu thut - Trong s 249 bnh nhn c 1 bnh nhn (0,4%) b chy mu phi can thip li ngay cm mu. T l ny theo Adam D Rubin i vi m tuyn gip t 0,3-1% (4).

y l bin chng him gp hin nay do k thut cm mu tt, nht l dao in cm mu c s dng mt cch thng quy. - C 5 bnh nhn c suy h hp sau m trong 2 trng hp (0,8%) phi m kh qun cp cu tm thi, canul m kh qun c rt sau 5 ngy. Trong 131 bnh nhn Trn Minh c c 7 bnh nhn phi m kh qun (2). Theo ng Ngc Hng sau m cc loi bnh tuyn gip th bin chng suy h hp hay gp nht l ung th tuyn gip vi t l l 33,3% (3). Ngoi nguyn nhn do tng tit m ri n cn do lit dy thanh m 2 bn. Hin tng ny xy ra ngay sau khi rt ng ni kh qun. C 2 dy thanh m u nm pha cnh gia gy ra tc ng th bn phn. Bnh nhn th rt ging i v kh th d di (4).Tt c cc trng hp suy h hp m khng m kh qun th u c iu tr bng th oxy, nm u cao, dng cc thuc chng vim gim ph n. Tnh trng bnh nhn s c ci thin dn. - Nut sc tm thi (2%) v ni khn tm thi (11,4%) xy ra khi c tn thng tm thi ca dy thn kinh thanh qun trong qu trnh bc tch ly u. Theo R.Sim ph n thanh qun ni ti l nguyn nhn hay gp nht ca khn ging sau m tuyn gip (10). T l tn thng dy thanh qun qut ngc khi nhn thy r v tch ra l 0-2% (4). H canxi mu tm thi gp 19 bnh nhn (7,7%). Chng ti nhn thy nu trong khi m m thy nhiu tuyn cn gip phi bc tch ra th sau m s c nhiu nguy c b h canxi mu.V trong qu trnh bc tch vic ng chm vo tuyn, vo mch mu s lm ph n t s lm gim vic cung cp mu cho tuyn (4).Cc bin chng ny s tng ln cng vi vic no vt hch(12). Trong 249 bnh nhn m c 1 trng hp h canxi mu vnh vin (0,4%).T l ny theo cc thng bo chim t 1 n 4% (4,8,12). - C 2 bnh nhn (0,8%) t vong, c 2 trng hp u trn 70 tui, bu to IV ; khi m bu xm ln vo cc c quan vng c. phu thut ct gn ton b tuyn gip li phn thm nhim vo kh qun nhng sau m b suy h hp v suy tim cp. Gia nh xin v v bnh nhn t vong ti nh. y l 2 bnh nhn trong s nhng bnh nhn u ca 249 bnh nhn m. T i vi nhng bnh nhn gi yu, u to xm ln rng c du hiu chn p th chng ti ch ly b mt phn t chc hoi t gim bt chn p ch khng t vn ct ton b. Qua 161 trng hp cht do ung th tuyn gip Yutaka Kitamura thy rng cht do suy h hp l 43%, do suy tim 15%, chy mu 15%, tc ng th 13% (11) 5. KT LUN - Ung th tuyn gip hay gp n hn nam gii. Cc du hiu lm sng thng khng rm r v rt d b b qua giai on sm ca bnh. - Chc ht t bo bng kim nh l phng php cn lm sng c gi tr nht hng ti chn on ung th tuyn gip trc khi m. - Phu thut ct ton b tuyn gip hay ct ton b c no vt hch vn l phng php ch o ca phu thut ung th tuyn gip. - Ung th bit ho th nh v th nang l ch yu chim 94% cc trng hp. - Cc bin chng v di chng sau m i vi tuyn cn gip v dy thn kinh thanh qun qua 249 trng hp m u t l thp.

TI LIU THAM KHO

1.

Nguyn B c: Ung th tuyn gip trng. Hng dn thc hnh chn on iu tr ung th. NXB Y hc, Hani, 1999, tr 135-149. 2. Trn Minh c, ng Ngc Hng, L Th Trung: Lm sng v iu tr ngoa khoa bnh nhn ung th tuyn gip ti bnh vin 103. Thng tin y dc s 8 / 2003, tr 29-33. 3. ng Ngc Hng, Ng Vn Hong Linh, Nguyn Ngc Trung, ng Thanh: Mt s nhn xt v bin chng suy h hp sau m cc bnh tuyn gip. Thng tin y dc s 1/2002,tr 24-28. 4. Adam D Rubin: Complication of thyroid surgery. http://www.emedicine.com/ent/topic649.htm 5. Ashok R.Shaha: Thyroid cancer: Extent of Thyroidectomy. Cancer control. 2000 ; 7 ;3: 240 - 245. 6. Corrias and All: Accuracy of fine needle aspiration biopsy of thyroid nodules in detecting malignancy in childhood:comparison with conventional clinical,laboratory,and imaging approaches.The Journal of Clinical Endocrinology &Metabolism 2001 ;86 ;10:4644-4648.