30

BNH HC U
Mc tiu hc tp 1. Phn bit c cc nh ngha trong bnh hc u 2. Bit v phn tch c thnh phn cu to ca m u 3. Bit cch gi tn u lnh tnh v u c tnh 4. Bit c cc nguyn nhn gy ung th chnh ngi 5. Hiu v bit cch phn ung th, nh gi giai on ung th ni chung v mt s ung th c bit

I. I CNG
U l mt khi m pht trin bt thng, sinh sn tha, tng trng qu mc v khng ng b vi cc m bnh thng ca c th to ra mt m mi nh hng n hot ng cng nh chc nng ca mt c quan no trong c th. S tng sinh t bo u c tnh t ng do mt s p ng vi cc kim sot bnh thng ca c th, khi u vn tip tc pht trin d kch thch gy ra u ngng. Khi u sng trn c th ngi bnh nh vt k sinh, tranh ginh cc cht dinh dng vi cc t bo v m bnh thng ca k ch (ngi bnh).

II. NGUN GC U
U c th sinh ra t bt c m no ca c th nhng c nhng m, c quan hay xut hin u hn. V d nh u biu m nhiu hn u lin kt t 5 n 10 ln. Ty theo cc yu t a d, mi trng sng, iu kin sinh hot v yu t chng tc, tn s sinh u cng thay i theo. Trong vi thp k qua, ngi ta nhn thy tnh cht ca mt s ung th nh: Ung th phi tng nhanh ti nhng quc gia v ang pht trin, ung th v tng mnh n gii; ung th d dy bt u gim t t ti M (t l mc bnh l 7,2/100.000 dn) trong khi t l ny Nht l 46,6/100.000 dn, gp gn 7 ln, cn Vit nam, ung th d dy ng hng th 2, chim 16% tng s cc loi ung th. Ung th biu m tuyn tin lit Vit nam kh thp trong khi n li chim t l rt cao M. Hu ht cc u pht sinh ra t nhng t bo ca bn thn c th b bin i, tr u nguyn bo nui li sinh ra t t bo phi thai l nhng t bo ca mt c th khc. i a s cc u u c nhng t bo sinh ra t mt loi t bo ngun, ch c mt s nh xut pht trn hai loi t bo kt hp gia m biu m v m lin kt, v d: ung th biu m - lin kt (epithelio-sarcoma) ca t cung, u mm thn hay u Wilms ...

III. MT S NH NGHA
1. S qu sn (hyperplasia) Cn gi l tng sn. L s gia tng s lng t bo lm cho m v c quan qu sn tng th tch. Cc t bo vn bnh thng v hnh dng v kch thc. C hai loi qu sn: 1.1. Qu sn ti to V d: - Qu sn tuyn v trong k dy th, mang thai v cho con b. - Mt thn b h hoc ct b, thn cn li s qu sn (qu sn b tr).

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Hnh 1. qu sn thy tuyn v

1.2. Qu sn chc nng V d: - Qu sn ni mc t cung do t cung do tng estrogen - Qu sn tuyn gip trong bnh Basedow. Qu sn l tnh cht c th v ph bin ca u nhng cng c th thy trong vim. Qu sn c th hi phc. Cn phn bit qu sn vi ph i (hypertrophy) l tnh trng tng kch thc v th tch ca t bo hoc mt c quan lm cho vng m v tng to hn bnh thng (khng gia tng s lng t bo). V d: - C t cung lc bnh thng: 20 micromet, lc c thai ph i 208 micromet. - C bp ph i do tp th dc. 2. D sn (metaplasia) Cn gi l chuyn sn. L s thay th mt loi t bo bit ha ny bng mt loi t bo bit ha khc. V d: - Cc t bo tr nim mc ph qun c th c thay th bng cc t bo biu m lt tng do ht thuc l kinh nin hoc do thiu vitamin A. - Trong cc so x cc nguyn bo si c th thay th bin i thnh cc nguyn bo xng v t bo to xng. D sn c th hi phc. 3. Lon sn (dysplasia) Cn gi l nghch sn. L s qu sn v thay i phn no cht lng t bo v m nhng vn nm trong s iu chnh ca c th. Cc t bo lon sn c c im l thay i v hnh dng, kch thc t bo. Cc t bo mt nh hng bnh thng, s lng t bo gia tng, hnh nh phn bo nhiu hn tuy nhin vn trong gii hn bnh thng. Lon sn c th chia lm 2 loi: 3.1. Lon sn n gin - T bo qu sn va phi

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- S xp lp t bo cn nguyn vn, t bo c cc tnh r - Nhn t bo kh u nhau - Bit ha t bo r rng 3.2. Lon sn trm trng - T bo qu sn mnh - Nhn t bo khng u nhau - Nhiu t bo non kim tnh - S xp lp v bit ha vn tn ti

Hnh 2. Lon sn vy thanh qun II

Lon sn c th hi phc nhng nu khng iu tr c th dn n ung th. Tuy nhin, gia ung th thc s v lon sn khng phi d dng phn nh m phi xem xt cn thn nhiu ln, nhiu v tr v theo di lu di. 4. S thoi sn (anaplasia) Cn gi l bt thc sn hay gim sn. L hin tng t bo pht trin ngc vi qu trnh tin trin v bit ha bnh thng. Kt qu l to nn mt cu trc m v t bo khc bit vi m v t bo gc, gn ging vi t bo phi thai. Cc t bo ny mt s bit ha v cu trc v chc nng, c kch thc v hnh dng t bo rt a dng, mt nh hng hon ton. Thoi sn l tn thng khng th hi phc, l c im quan trng ca ung th nhng khng phi tt c cc t bo ung th u gim bit ha r rt m trong mt khi u c th c nhiu mc bit ha khc nhau.

IV. CU TO CA M U
Cng nh m bnh thng, u cng c cc t bo c s v cht m. 1. Khi u ch gm mt loi t bo a s khi u ch c mt loi t bo, v d: u x (fibroma) ch yu gm cc t bo x trng thnh. 1.1. C bn u C bn u l thnh phn c s ca u, da vo ta c th phn nh u thuc v thnh phn biu m hay lin kt hay c hai. Nu u thuc v biu m th c bn u v cht m u phn bit vi nhau r rt, cn nu thuc v m lin kt th kh nhn ra gia c bn u v cht m u. V d: - U tuyn ni mc t cung c th phn bit d dng gia cc tuyn qu sn vi cht m l m x, c trn v huyt qun.

33
- U x - c (u lin kt) kh phn bit u l u, u l m x m ca n. 1.2. Cht m u Cht m u l khung lin kt - huyt qun, c vai tr nui dng t bo c bn u. Thnh phn cht m gm c: - M lin kt - Huyt qun v bch huyt qun - Cc nhnh thn kinh - Cc t bo phn ng nh lympho bo, i thc bo, bch cu a nhn ... 2. Khi u c nhiu loi t bo 2.1. Khi u c nhiu loi t bo xut pht t mt l thai: Gi l u hn hp. V d: U hn hp tuyn nc bt 2.2. Khi u c nhiu loi t bo xut pht t nhiu l thai: Gi l u qui (teratoma) v thng gp bung trng v tinh hon. V d: U nang dng b bung trng

V. CCH GI TN U
1. U lnh Cc u lnh c tn gi tn cng bng OMA. 1.1. U lnh c ngun gc lin kt Tn u = tn ca t bo gc + OMA V d: - Fibroma (fibro: x): U x lnh - Lipoma (lipo: m): U m lnh - Osteoma (osteo: xng): U xng lnh - Chondroma (chondro: sn): U sn lnh 1.2. U lnh c ngun gc biu m Tn gi c th phc tp hn, c th cn c vo t bo gc ca u hoc cc c im vi th, i th u. 1.2.1. Da vo hnh nh vi th: V d: Adenoma (adeno: tuyn): U tuyn lnh, c th gp nim mc i trng, d dy, tuyn gip, tuyn v, tuyn tin lit ... 1.2.2. Da vo hnh nh i th: V d: - Papiloma (papi:nh): U nh. Gm nhiu nh hnh kim, c th gp da (mn cc, si mo g), nim mc i trng ... - Cystadenoma (cyst: nang, adeno: tuyn):U tuyn nang. C th gp bung trng, tuyn v, ng mt, ty ... - Polyp: l nhng khi u c th c cung hoc khng, xut pht t cc nim mc nh polyp d dy, rut non, i trng, c t cung. 2. U c 2.1. Cc u c xut pht t m lin kt

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C tn gi tn cng bng SARCOMA. V d: - Fibrosarcoma: Ung th x - Liposarcoma: Ung th m - Osteosarcoma: Ung th xng - Chondrosarcoma: Ung th sn 2.2. Cc u c xut pht t biu m C tn gi tn cng bng CARCINOMA. V d: - Adenocarcinoma: Ung th biu m tuyn - Choriocarcinoma: Ung th biu m m nui - Hepatocarcinoma: Ung th biu m gan - Squamous cell carcinoma: Ung th biu m t bo vy Tuy nhin, c mt s loi ung th vn c tn gi c ui bng OMA nh: - Synovioma: ung th bao hot dch - Melanoma: ung th t bo hc t - Lymphoma: Ung th hch lympho

VI. C IM CA U LNH V U C
1. U lnh tnh C bn c im: - Pht trin ti ch v chm U lnh mc ti ch, thng l chm, khng lm cht ngi, tr phi mc vo v tr him yu. U c th c khi lng ln sau nhiu nm tin trin. - C ranh gii r rt Nhn i th, u lnh c v x bao bc do d bc tch ton b khi u. V d: u m lnh, u x tuyn v, u c trn t cung. Do , ch c xu hng chn p ch khng xm nhp. V d: U tuyn i trng, c rt nhiu tuyn Liberkuhn ch cht nhy nh tuyn bnh thng, cc tuyn vn nm trn c nim. - Ging nh m bnh thng V vi th, u lnh ti to li mt cch trung thnh cu trc ca m sinh ra n, khng c o ln cu trc. - U lnh him khi ti pht, khng di cn Nu u lnh c ct b trit , u khng mc li na, tr u dng l tuyn v. Khng bao gi thy u lnh theo cc ng mu hay bch huyt n mc ni khc xa ch u pht sinh (khng di cn). 2. U c tnh C 4 c im: - Pht trin nhanh Thng u c tnh pht trin nhanh, thng gy cht ngi t vi thng n vi nm. S bnh trng ca khi u khng bao gi ngng c. Theo nhng nghin cu mi y, khi u thng c pht hin khi t n kch thc 1cm, lc ny n c s lng khong 1 t t bo v tin trin c khong 6 nm k t khi chng c nhn i t mt t bo ung th u

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tin. Chu k nhn i kch thc khi u trong khong 45 ngy n 450 ngy. Sau thi gian 450 ngy m khi u khng tng ln gp i th khi u kh c kh nng l u c tnh. - Ranh gii khng r rt U c tnh c gii hn vi m lnh khng r rng, c nhiu r xm nhp, chnh v vy ung th c thut ng l cancer, ting la tinh c ngha l con cua, do cc khi u c tnh xm ln v bm cht vo cc m xung quanh nh nhng cng cua. - Khng ging m bnh thng V vi th, ni chung cc u c tnh qu sn mnh, ph v lp y, chui vo lp m gy o ln cu trc, to thnh nhng khi t bo m mu, nhn khng u, nhn qui, nhn chia. T bo u phn ln l t bo non (thoi sn), ch gi li phn no m gc ca u. - Rt d ti pht, di cn D ct b rng ri, do tnh cht xm nhp su v lan xa ca chng, cc m ung th d dng mc tr li hoc ti ch hoc di cn xa. Di y l bng so snh cc c tnh khc nhau gia u lnh tnh v u c tnh
So snh i th U lnh tnh U c v bc, d bc tch, ranh gii r rt, khng xm nhp, c tnh di ng khi s nn Cu to ging m lnh Khng c hay c t nhn chia, khng c hnh nhn qui, ht nhn U c tnh U khng c v bc, ranh gii khng r, xm nhp su vo m xung quanh, t di ng, to thnh mt khi cng chc Cu to khng ging m lnh, cu trc o ln C nhiu hnh nhn chia, nhn khng u, c ht nhn, nhn qui

Vi th

Tin trin

Tin trin chm, ti ch Tin trin nhanh Khng lm cht ngi, tr trng hp Gy cht ngi do chy mu, hoi t, tc c bit v tr nguy him mch, suy mn Khng c di cn Di cn Khi hn khi c ct b D ti pht, iu tr kh khn

iu tr

VII. NGUYN NHN SINH UNG TH

1. Cc ha cht sinh ung Cc ha cht sinh ung c cu to v cng khc nhau, n bao gm c cc sn phm c ngun gc thin nhin v nhn to gm c 2 loi: 1.1. Cc cht sinh ung tc ng trc tip 1.1.1. Cc tc nhn ankyl ha - - propiolactone - Dimethyl sulfate - Diperoxybutane 1.1.2. Cc tc nhn axyl ha - 1-Acetyl-imidazole - Dimethylcarbamil chloride 1.2. Cc cht sinh ung tc ng gin tip (cn phi qua qu trnh hot ha chuyn ha) 1.2.1. Cc cht hydrocarbon thm a vng v d vng - 7,12-dimethyl benzathracene

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- 3,4-benzopyrene - 3-methylcholathracene Khi xe, khi thuc l c cc hydrocarbon vng thm c th gy ung th. 1.2.2. Cc amin thm, cc amide v cc phm nhum nhm azo - -naphthylamine (gy ung th bng quang) - Benzidine 1.2.3. Cc sn phm t cc cy t nhin v cc loi vi khun - Alfatoxin B1 (do nm aspergillus flavus c trong u phng mc) gy ung th gan - Griseofulvin - Cycasin 1.2.4. Cc cht khc - Nitrosamine (chuyn ha t nitrite dng bo qun tht, khi vo d dy s chuyn thnh nitrosamine c th gy ung th d dy) - Vinylchloride, nikel, chromium - Cc thuc tr su, cc thuc dit nm 2. Cc cht phng x sinh ung Cc nng lng bc x hoc dng cc tia cc tm ca nh sng mt tri hoc di dng cc cht phng x c bit (in t ion ha), u c th gy chuyn dng hu ht cc t bo trn thc nghim v c th sinh ra ung th trn c th sng. ngi, cc cht phng x thng gy ung th theo mc th t sau: thng gp nht l bnh bch cu, sau l ung th tuyn gip, ung th v, ung th phi v ung th tuyn nc bt. Ngc li, cc m khc nh da, xng v h tiu ha li kh vng bn di tc ng ca cc tia phng x sinh ung. 3. Cc virus sinh ung C nhiu loi virus gy ung th ng vt v ngi. Chng c chia lm 2 nhm ln: cc virus DNA v virus RNA. 3.1. Cc virus sinh ung loi DNA 3 loi virus DNA hay gy ung th nht l Papiloma virus, Epstein-Barr virus v virus vim gan B. - Cc papiloma virus (HPV) Thng gy ra mt s cc loi u nh lnh tnh, mn ht cm da, u nh vng sinh dc, trc trng v thanh qun. ng thi n cn gy ra ung th da phi hp vi Epstein-Barr virus, ung th c t cung, ming v thanh qun. - Epstein-Barr virus (EBV) Virus ny thuc h Herpes. V sinh bnh hc, chng l nguyn nhn gy ra hai loi ung th ngi: U lympho Burkitt v ung th biu m mi hng khng bit ha. - Virus vim gan B (HBV) HBV thng gy thnh dch mt s a phng, ngi b nhim HBV c nguy c d b ung th gan cao gp 200 ln so vi ngi khng b nhim virus ny. 3.2. Cc virus sinh ung loi RNA Tt c cc virus RNA u thuc h Retrovirus, ngha l chng u c enzyme sao chp ngc. Enzyme ny cho php sao chp ngc t RNA virus thnh DNA c hiu ca chng. 4. Nguyn nhn bo thai

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C nhng t bo bo thai khng bit ha c v nm im trong c th n mt lc thun tin (tui, hormone, cc cht kch thch...) cc t bo ny c pht ng v pht trin sinh ra cc u. 5. Gim st min dch ca c th Ni chung nhng c th b suy gim min dch u c kh nng b ung th. Cc t bo c nng lc min dch khng nhn dng c cc t bo ung th hoc khng kh nng tiu dit chng. Mt s bng chng v t l ung th kh cao ngi b suy gim min dch: - 14/200 bnh nhn b mt hay thiu gamma globulin mc cc bnh: U lympho c tnh, bnh bch cu lympho cp, ung th lin vng. - 3000 trng hp ghp thn c iu tr bng huyt thanh chng lympho bo c ti 40 trng hp b ung th: ung th lin vng, u lympho c tnh, ung th d dy, ung th da v ung th mi. - Bnh nhn mc bnh AIDS (hi chng suy gim min dch mc phi) thng hay b sarcom h min dch.

VIII. PHN CA UNG TH

1. Theo m bnh hc Cn c vo mc bit ha ca t bo u v hnh thi, cu trc m nh gi mc c tnh. V d: Broders phn loi ung th t bo vy thnh 4 cn c vo s bit ha t bo: I: U c xu hng bit ha vi 75% hoc hn cc t bo bit ha II: 75 -50% cc t bo bit ha III: 50-25% cc t bo bit ha IV: di 25% t bo bit ha 2. Theo t bo hc Papanicolaou xp phin t bo m o - c t cung thnh 5 hng: Hng I: Khng c t bo bt thng hoc khng c t bo in hnh Hng II: T bo hc khng in hnh nhng khng c c tnh Hng III: T bo hc nghi ng c tnh nhng khng kt lun c Hng IV: T bo hc rt nghi ng c tnh Hng V: T bo hc xc nh l c tnh 3. Phn loi TNM Hin nay, h thng TNM c p dng rng ri v ph bin nht. - T (tumor): kch thc khi u T0: Khi u khng thy r trn lm sng Tis (in situ): ung th tin trin ti ch T1: Ung th nh, gii hn, khng hoc t xm nhp T2: Khi u to hn v / hoc xm nhp ph tng mt cch ti thiu T3: Khi u to hn v / hoc xm nhp rng ln ph tng v / hoc cc m ln cn T4: Khi u vt xa ph tng v / hoc xm nhp cc ph tng (hoc cu trc) ln cn - N (lympho node): tnh trng di cn hch lympho N0: Khng c hch di cn N1: C hch cng bn, di ng

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N2: Hch c 2 bn, i xng, di ng N3: Hch khng di ng - M (metastasis): di cn xa M0: Khng c du hiu di cn xa M1: C di cn xa nh gi giai on lm sng TNM rt quan trng v c p dng rng ri trn ton th gii v n quyt nh phng thc iu tr v tin lng.