i cng v Ung Th V

I. i cng: Ung th v l loi Ung th gy t vong nhiu nht ph n. Hi ung th M c tnh Ung th v chim 32% ton b Ung th mi v 18% s t vong do Ung th ph n. T l b Ung th v hng nm Hoa k tng ln rt mnh theo tui (5/100 000 tui 25 tng ln 150/100 000 tui 50 v hn 200/100 000 tui 75). Ti Vit nam hin vn cha c s liu thng k y , nhng Ung th v ang tr thnh loi Ung th ng hng u trong cc loi Ung th ph n.

II. Nguyn nhn, bnh sinh: 1. Nguyn nhn: + t bin Gen: Thng thy t bin Gen BRCA1 v Gen p53 nm trn Nhim sc th 17, Gen BRCA2 nm trn Nhim sc th 13. Yu t gy t bin Gen c th l cc Tia phng x hay Virut. + Di truyn: Khong 18% Ung th v c yu t di truyn nhng ch khong 5% l thc s c yu t gia nh. Trong nhng gia nh ny, nguy c b Ung th v c i n t nht l 50%. + Ch n v Hocmon: - Ch n nhiu m v ng c t l b Ung th v cao hn ch n t ng v m, c bit l i vi la tui tr. - Mt s loi Hocmon nh : Prolactin, Estrogen, Progestin (thng c trong cc thuc chng thai) khi dng lu di c th lm tng nguy c Ung th v nhng ph n tr. 2. Cc yu t nguy c ca Ung th v : + Cc yu t c nguy c cao (lm tng kh nng b bnh hn 3 ln): Tui trn 40; b Ung th trc y mt bn v; Ung th v gia nh; Tng sn tuyn v khng in hnh; Khng c con; C thai ln u mun (sau tui 31); Hi chng Klinefelter; Bnh ph i tuyn v nam gii; Tin s gia nh c nam gii b Ung th v. + Cc yu t nguy c trung bnh (tng kh nng b bnh 1,2-1,5 ln): Bt u c kinh nguyt sm; Mt kinh mun; Ung nhiu Estrogens; C tin s b Ung th bung trng, y t cung hoc i trng; i tho ng; Dng nhiu cht ung c cn. III. M bnh hc: 1. Phn loi m bnh hc Ung th v theo t chc y t th gii:

a) Ung th biu m tuyn tuyn v: + Ung th biu m tuyn khng xm nhp: - Cacxinom ni ng tuyn ( intraductal carcinoma). - Cacxinom thu tuyn in situ (Lobular Carinoma in situ). + Ung th biu m tuyn xm nhp: - Cacxinom ng tuyn xm nhp (invasive ductal Carinoma). - Cacxinom ng tuyn xm nhp ch yu thnh phn ni ng. - Cacxinom thu tuyn xm nhp (invasive lobular carcinoma). - Cacxinom th nhy (mucinous carcinoma). - Cacxinom th tu (medullary carcinoma). - Cacxinom th nh (papillary carcinoma). - Cacxinom th tr (tubular carcinoma). - Cacxinom th nang dng tuyn (adenoid cystic carcinoma). - Cacxinom th bi tit tui thiu nin (secretory (juvenile) carcinoma). - Cacxinom th tit rng u (Apocrine carcinoma). - Cacxinom c tnh trng d sn (carcinoma with metaplasia) * Cacxinom dng t bo vy (squamous) * Cacxinom dng t bo hnh thoi (spindle) * Cacxinom dng t bo xng v sn. * Cacxinom dng cc t bo hn hp. - Cc loi Ung th biu m tuyn xm nhp khc. + Bnh Paget nm v.

b) Ung th hn hp t chc biu m v t chc lin kt tuyn v: + Ung th dng t bo l (Cystosarcoma phylloides) + Caxinosacom tuyn v (carcinosarcoma). c) Cc loi Ung th khc (khng phi ca biu m tuyn v): + Angiosarcoma + Cc loi Sacom khc ca t chc m, x, thn kinh... 2. c im gii phu bnh l mt s Ung th tuyn v: + Cacxinom ng tuyn: Chim khong 78% s Ung th v. Thng ch b mt v. C th gp Cacxinom ng tuyn xm nhp hoc Cacxinom ng tuyn khng xm nhp. + Cacxinom thu tuyn: Chim khong 9% s Ung th v. Thng b c hai v. Thng c pht hin thy mc in situ (c ngi coi loi ny l tin Ung th). + Cacxinom th tu: Chim khong 4% s Ung th v . Gm cc t bo khng bit ho v xm nhim Lympho rt mnh. + Cc th c bit c tin lng tt: Chim khong 10% s Ung th v. Gm cc Cacxinom th Nh n thun, Cacxinom th tr, Cacxinom th nhy... + Bnh v Paget: Biu hin di dng tn thng Eczema ca u nm v mt bn, thng i km vi Cacxinom ng tuyn ph n. IV. Triu chng lm sng : Triu chng lm sng ca Ung th tuyn v rt a dng, khi c cc triu chng in hnh th thng giai on mun ca bnh.

1. Cc triu chng ti tuyn v : a) Khi to ln v : L triu chng c 90% s bnh nhn Ung th v. C th xc nh c cc tnh cht sau : + V tr : thng b mt v nhng c khi b c hai v. + Cc bin i da vng c khi U: - Du hiu da trn khi U b lm xung v dnh vo khi U: nhn r khi cho bnh nhn dang thng cnh tay bn c U ra v nhn di nh sng tt. - Du hiu da kiu v cam: nhn r mt mng da b ph n, i mu xm v c nhng im b lm su xung ch chn lng. - Nhng trng hp n mun c th thy da trn khi U b lot ra, chy mu, bi nhim... + Mt : thng chc hoc cng. + B mt : thng li lm khng u. + Ranh gii : thng khng r rng v tnh trng xm nhim ca U vo cc t chc xung quanh. + Kch thc : to nh tu tng trng hp. + Di ng km : do dnh nhiu vo t chc xung quanh, nht l da v c ngc ln. + Thng khng au. + Cn ch l c loi Cacxinom tuyn v biu hin ging nh mt vim tuyn v: da trn tuyn v ph n, , nhim cng, au... b) Nhng bin i nm v: + Chy dch u nm v : Chy dch u nm v t pht c th gp khong 20% s ph n Ung th v. Trong cc trng hp ny dch nm v c th l : dch nc trong, mu, dch thanh t ln mu, dch thanh t...

+ u nm v co vo hoc tt su vo trong: do khi U xm nhim v ko rt cc ng tuyn sa v pha U. + Trong th bnh Cacxinom Paget: vng nm v thng c biu hin nh mt tn thng Eczema ca nm v. 2. Hch nch: Hch nch cng bn to ra chng t c di cn Ung th ti phm vi khu vc. Cn xc nh cc tnh cht ca hch nch v: s lng, ln, mt , tnh trng dnh ca hch vo nhau v vo t chc xung quanh... Ch khm c hch nch bn i din xc nh di cn xa. V. Triu chng cn lm sng: 1. Sinh thit chn on: a) Vi cc khi U c th s thy r rng: + Sinh thit ht t bo bng kim nh (Fine-needle aspiration biopsy): L mt xt nghim c th thc hin nhanh chng v an ton, c nhy t ti 90-98% (ph thuc ch yu vo k nng v kinh nghim ca xt nghim vin). Bnh phm c a i xt nghim t bo hc v c th c dng xc nh cc th cm th Estrogen v Progesterone bng k thut ho t bo min dch. + Sinh thit li ( Core biopsy ): Dng kim Tru-Cut (Baxter) ly ra mt phn t chc khi U. Bnh phm a i xt nghim m bnh hc v xc nh cc th cm th Estrogen v Progesterone. + M sinh thit mt phn khi U (Incisional biopsy): Thng rch da theo ng Langer (ng rch cong, i st v song song vi qung nm v). Bc tch v ct ly mt phn khi U a i lm xt nghim. Ch nh khi mun nh gi mt khi U v ln nghi ng l c tnh m sinh thit ht kim nh hoc sinh thit li khng xc nh c chn on + M ct khi U sinh thit (Excisional biopsy):

M bc tch ly khi U a i xt nghim. b) Vi cc U khng s thy c r rng: + Sinh thit c nh v bng kim (Needle localized biopsy): Di hng dn ca chp v, chc kim km dng c c dy mc c bit vo tuyn v ni tip gip vi ch bnh l nh v ch cn sinh thit. Sau tin hnh m sinh thit khi bnh l ng ch c nh v. + Sinh thit li bng kim c nh v ba chiu (Stereotactic core needle biopsy): S dng b nh v ba chiu bng my tnh in t nh v tn thng, tip dng dng c bn t ng xuyn mt lc nhiu kim sinh thit li vo vng tn thng ly bnh phm. 2. Chp v (Mammography): C th pht hin c 85% Ung th v, k c cc U cha s thy trn lm sng. Nhng du hiu c th gp trn phim chp v trong Ung th v l: + Cc vt lng ng Canxi. + Hnh cc ng tuyn v b xon vn hoc khng cn i. + Da vng tuyn v v nm v dy ln + Hnh khi c tuyn v. 3. Chp siu m tuyn v: C th dng phi hp vi Chp v chn on phn bit U v l mt khi U c hay U nang. 4. Chp CT tuyn v: Thng theo di tnh trng cc hch v trong, lng ngc v vng nch sau khi m ct tuyn v. 5. Chp MRI tuyn v: C th dng khi cc phng php chn on hnh nh khc khng cho kt qu r nt.

6. Chp nhit tuyn v: Da trn s phn b nhit khc nhau ca t chc v bnh thng v Ung th ghi li hnh nh nhit ca Ung th v. Hin nay t dng do hiu qu chn on khng cao. VI. Cc th lm sng: Do biu hin lm sng ca Ung th v rt a dng nn cc th lm sng ca Ung th v cng rt phc tp. 1. Ung th v dng U c n c: y l loi hay gp. Triu chng thng tng i in hnh. 2. Ung th v dng U nang: Khi U c th di dng mt nang n c, ranh gii r. Chc ht nang c th thy dch ln mu. 3. Ung th v dng vim: Biu hin ging nh mt vim cp tuyn v: sng n, tin trin nhanh. 4. Ung th v dng no: U pht trin nhanh gy hoi t t chc tuyn v ging nh cht no. 5. Ung th v dng x cng: Tuyn v ung th pht trin t chc x ho rt mnh, teo qut li, dnh cht vo da v thnh ngc. C khi to thnh mt mng nhim cng rng b cht ly lng ngc. 6. Ung th v Nam gii: Chim khong 0,5-1% s Ung th v ni chung, thng ngi gi. 7. Ung th v ph n c thai: Khong 2% s bnh nhn Ung th v c chn on ra khi bnh nhn ang mang thai

VII. Phn chia giai on Ung th v theo h thng TNM: Phn chia giai on Ung th v theo h thng TNM ca Hip hi quc t chng Ung th (International Union Against Cancer: UICC) nm 1992 nh sau: 1. H thng phn chia TNM trn lm sng: + Khi U nguyn pht ( T ): - Tx Khng th xc nh c khi U - T0 Khng c khi U - Tis Cacxinom in situ (cacxinom ni ng tuyn, cacxinom thu tuyn in situ, bnh Paget nm v khng c U) - T1 U c ng knh ln nht < 2 cm * T1a U c ng knh ln nht < 0,5 cm * T1b U c ng knh ln nht > 0,5 cm v < 1 cm * T1c U c ng knh ln nht > 1 cm v < 2 cm - T2 U c ng knh ln nht > 2 cm v < 5 cm - T3 U c ng knh ln nht > 5 cm - T4 U c ng knh bt k nhng xm nhim vo thnh ngc hoc da * T4a U xm nhim vo thnh ngc * T4b U xm nhim da gy ph n da (c du hiu da kiu v cam), lot da hoc c cc khi cc nh da gn cht vi tuyn v. * T4c U c c T4a v T4b * T4d Cacxinom tuyn v th vim

+ Hch bch huyt khu vc ( N ): - Nx Khng th xc nh c hch khu vc - N0 Khng c di cn hch khu vc - N1 di cn hch nch cng bn v hch cn di ng * N1a Ch di cn vi th (hch < 0,2 cm) * N1b Hch nch di cn c kch thc > 0,2 cm . N1bi C 1-3 hch di cn, cc hch c ng knh ln nht > 0,2 cm v < 2 cm . N1bii C > 4 hch di cn, cc hch c ng knh

ln nht > 0,2 cm v < 2 cm . N1biii Hch di cn c ng knh < 2 cm nhng tn thng vt ra khi bao ca hch. . N1biv Hch di cn c ng knh ln nht > 2 cm

- N2 di cn hch nch cng bn, cc hch ny dnh vo nhau v vo cc t chc xung quanh. - N3 di cn vo cc hch v trong cng bn + Di cn xa ( M ): - Mx Khng th xc nh c c di cn xa - M0 Khng c di cn xa - M1 c di cn xa (k c di cn hch trn n cng bn) 2. Phn chia giai on Ung th v theo h thng TNM: + Giai on 0 Tis N0 M0

+ Giai on I + Giai on IIA

T1 T0 T1 T2

N0 N1 N1 N0 N1 N0 N2 N2 N2 N1 N2

M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0

+ Giai on IIB

T2 T3

+ Giai on IIIA

T0 T1 T2 T3 T3

+ Giai on IIIB

T4 Mi T

Mi N M0 N3 M0

+ Giai on IV VIII. Chn on phn bit:

Mi T

Mi N M1

1. Cc bnh l di dng mt khi to ln v: + Khi cc t chc biu m tuyn v do ni tit (Lump) + Cc U lnh tnh ca t chc biu m hoc t chc lin kt ca tuyn v: U nh ni ng tuyn, U tuyn ca nm v, U tuyn th tr, U tuyn tit sa, U x tuyn, U t chc phn mm tuyn v, U t chc da tuyn v, U mch mu, U bch mch + Cc bnh v x nang v lon sn. + Cc tn thng dng u tuyn v: gin ng tuyn sa, khi vim gi u tuyn v, hoi t m sau chn thng, vim hch bch huyt, ph i tuyn v Nam gii

2. Cc bnh l c chy dch nm v: + U nh ni ng tuyn + U nang tuyn sa; Gin ng tuyn sa 3. Cc bnh l c bin i da v nm v: + Vim tuyn v; Apxe tuyn v + Bnh Mondor: vim nghn tnh mch nng vng tuyn v IX. D phng v pht hin sm: 1. T kim tra tuyn v: + Hng thng i vi tt c ph n trn 20 tui. + Nhng ph n tin mn kinh nn thc hin kim tra 5 ngy sau ngy kt thc ca mt chu k kinh. + Nhng ph n sau mn kinh nn t kim tra mnh cng vo nhng ngy nh vy mi thng. 2. n khm lm sng ti c s c bc s: + Ba nm mt ln cho cc ph n la tui 20-40. + Mi nm mt ln cho cc ph n trn 40 tui. 3. Chp v: + Cc ph n 35-39 tui cn phi c chp v kim tra lm s liu c s theo di sau ny. + Cc ph n 40-49 tui cn c chp v 1-2 nm mt ln. + Cc ph n trn 50 tui cn c chp v mi nm mt ln. 4 Ct tuyn v d phng: C th ch nh cho cc trng hp sau :

+ Cc bnh nhn c bnh v lnh tnh v c tin s gia nh b Ung th v hai bn tui tin mn kinh. + Bnh nhn c tin s b Ung th v v hin nay ang c bnh x nang trong tuyn v cn li. + Cc bnh nhn b Caxinom th thu in situ. X. iu tr: 1. Ung th v giai on I v II (giai on bnh cn kh tr ti ch): Trong giai on ny, bin php iu tr quan trng hng u l phu thut, cc bin php iu tr khc ng vai tr b xung v cng c. a) Cc phng php phu thut: + Ct tuyn v trit : - Tin hnh ct b ton b tuyn v km cc c ngc ln v nh, ly b ton b hch bch huyt dc theo tnh mch nch ln n dy chng sn n (dy chng Halsted). Phu thut ny c Halsted a ra u tin vo nm 1894 nn thng c gi l phng php Halsted. - Hin nay t dng v li khuyt hng ln thnh ngc bnh nhn v kt qu iu tr ni chung khng khc cc phng php ct tuyn v trit ci bin. + Ct tuyn v trit ci bin: - Tin hnh ct b ton b tuyn v km ly b hch nch thnh mt khi, khng ct b c ngc ln. Cc phng php hay dng l: * Phu thut Patey: ct b ton b tuyn v, ct b c c ngc b c th ly b c cc hch nch cao trn nh h nch. * Phu thut Patey ci bin (Scanlon): cng lm nh phng php Patey nhng khng ct b c ngc b m ch bc tch n c th ly b cc hch nch cao v bo tn c dy thn kinh ngc bn (chi phi c ngc ln). * Phu thut Auchincloss: thc hin ging phng php Patey nhng khng ct b hay bc tch c ngc b c ly b cc hch nch cao. - Hin nay, y l bin php phu thut chun i vi Ung th v giai on bnh cn kh tr. Ly b hch nch va iu tr va chn on giai on bnh.

- u im: * L bin php ng tin cy v hiu qu nht x l khi U ti ch v gii quyt trit nguy c pht trin cc khi U nguyn pht mi. * Nu cn iu tr ho cht b xung th vic thc hin n sau iu tr phu thut s d hn nhiu so vi sau iu tr Chiu x. - Nhc im: * Khuyt hng v mt thm m. * C cc bin chng sau m: Ph bch mch, tn thng dy thn kinh m ri cnh tay... + Phu thut ct b rng ti ch km Chiu x ngay sau m: - Phu thut ct b rng ti ch cn gi l phu thut ct mt phn tuyn v, phu thut ct thu tuyn v, phu thut ct khi U vNi dung ca phu thut ny l: * Ct b khi Ung th cng mt phn t chc nhu m tuyn v lnh xung quanh. C th ct b rng ra 1-2 cm vo t chc lnh quanh khi U km ly b c t chc da nm ngay trn khi U (phu thut ct mt phn tuyn v: quadrantectomy). * Rch mt ng ring bc tch ly b hch nch. - Chiu x ngay sau m: thng dng tia Gamma hiu in th rt cao cho ton b tuyn v (khong 4500-5000 cGy bng chm tia in t hoc ng phng x Iridium192). Ton b thi gian m v chiu x ngay sau m l khong 6 tun. - u im ca phng php: * Gi c v ngoi thm m. * Gi li c tuyn v. - Nhc im: * T chc tuyn v cn li c th b Ung th ti pht hoc pht trin Ung th v nguyn pht mi.

* C cc bin chng do Chiu x ko di nh: ban da, lot, vim x tuyn v, gy xng sn, sinh Ung th mun, vim phi v vim mng ngoi tim do tia x... b) iu tr b xung sau phu thut: Hu ht cc Cacxinom xm nhim tuyn v u c coi l c di cn vi th ngay thi im khi u ca vic iu tr. Do vic iu tr b xung phi c thc hin ngay sau khi iu tr ti ch c th tc ng ti cc di cn vi th cn li. + Chiu x: - Sau phu thut ct b tuyn v trit ci bin th vic Chiu x b xung sau m ni chung khng cn thit, tr cc trng hp c rt nhiu hch nch di cn. - Sau cc phu thut ct b rng ti ch (ct b mt phn tuyn v) th Chiu x c coi l bin php bt buc i km ngay sau m. + Ho cht: - Thng dng cc phc phi hp nhiu loi thuc c hiu qu iu tr tt hn. Cc phc phi hp thuc hay dng l: * CMF: Cyclophosphamide, Methotrexate, 5-fluorouracil * FAC: 5-fluorouracil, Adriamycin, Cyclophosphamide * CA: Cyclophosphamide, Adriamycin - Thng dng ho cht iu tr b xung bt u sau m 4 tun v mt t ko di khong 6 thng. + Ni tit: - Cc thuc ni tit thng c dng l: Tamoxifen citrate (Nolvadex), Megestrol acetate (Megace), Aminoglutethimide (c tc dng ph hu chc nng tuyn thng thn), Estrogen (diethylstilbestrol), Androgen (fluoxymesterone)... - Vic ch nh dng thuc Hocmon cn da vo xt nghim xc nh th cm th Estrogen v Progestogene ca t bo Ung th v. Ni chung nu cc th cm th ny dng tnh th iu tr bng Hocmon s c hiu qu cao.

- Ngoi cc thuc Ni tit ni trn, cc bin php khc cng c ngha iu tr ni tit l: * Ct b bung trng: c hiu qu iu tr rt tt i vi nhng ph n tui tr. * Ct b Tuyn thng thn hay ct b Tuyn yn. + Min dch: C th dng cc bin php iu tr min dch nh: tim chng BCG, ung Levamisole nhng kt qu khng r rng. + Trong thc t iu tr cc bin php iu tr b xung ni trn lun c s dng phi hp vi nhau, kt qu thu c cho thy: - Kt hp iu tr Ho cht v Ni tit cho hiu qu cao hn dng chng n thun. - iu tr ho cht bng cc phc kt hp thuc c hiu qu cao hn nhiu so vi iu tr mt loi thuc n thun. 2. Ung th v giai on IIIA ( cn c th phu thut c): ng hng chung l phi iu tr kt hp: + iu tr Chiu x ti ch v khu vc hn ch bt s pht trin ca khi U. ng thi dng ho cht iu tr cc di cn c th c ton thn. Sau tin hnh phu thut ct b ton b tuyn v km bc tch ly b hch nch. + Sau m tip tc iu tr b xung bng Chiu x, Ho cht, Ni tit 3. Ung th v giai on IIIB (khng cn kh nng phu thut): ng hng iu tr chung l: + iu tr ngay t u bng ho cht. Dng phc kt hp thuc CMF, CA hay FAC trong 3 hoc 4 thng. + Tip iu tr Chiu x ti ch v khu vc, ri tin hnh m ct b ton b tuyn v. + Cui cng li tip tc iu tr ton thn bng Ho cht (phc phi hp thuc CMF hoc FAC), Ni tit (Tamoxifen...)

4. Ung th v giai on IV (giai on di cn ton thn): Thng iu tr ngay bng Ho cht hay Ni tit . a) iu tr Ni tit: + Phi da vo xt nghim xc nh th cm th Estrogen (ER) v Progesterone (PgR) trong tiu bn bnh phm U ch nh dng cc thuc Ni tit. Khi cc th cm th ny dng tnh th iu tr bng Ni tit mi c th c hiu qu cao. + Cc thuc Ni tit hay dng l: - Tamoxifen citrate (Nolvadex), 20 mg/ mt ngy: c dng lin tc cho n khi bnh nhn b ti pht tr li. - Megestrol acetate (Megace), 40 mg dng 4 ln/ngy. - Aminoglutethimide, 250 mg ung 4 ln/ngy: c dng cho cc bnh nhn c p ng nhng sau li km p ng vi iu tr ni tit. Thuc to nn tnh trng ct b tuyn thng thn bng thuc. Phi dng Hydrocortisone d phng ri lon trc Tyn yn-Thng thn. Thng dng Hydrocortisone ung sng, chiu v ti, mi ln ung 10 mg. - Cc thuc khc: Estrogen (diethylstilbestrol, 5 mg dng 3 ln/ngy) hoc Androgen (fluoxymesterone, 10 mg dng 4 ln/ngy). Thng dng cho cc bnh nhn c p ng nhng sau li khng p ng vi iu tr bng Tamoxifen, Megestrol acetate, hay Aminoglutethimide. + Ct b bung trng: - Ch nh dng cho cc bnh nhn n di 50 tui, b Ung th v ti pht vi th cm th Estrogen dng tnh. C tc dng ci thin r rt thi gian sng thm v gim t l ti pht trn nhng bnh nhn ny. - C th ct b bung trng trc tip bng phu thut, bng chiu x hoc dng thuc (Leuprolide, Zolodex). + M ct b Tuyn thng thn hay ct b Tuyn yn: c th gy ra nhng vn kh khn trong theo di v iu tr do ch nh p dng rt hn ch. b) iu tr Ho cht:

+ Phc CMF c hiu qu tt cho iu tr khi u, nht l khi kt hp vi Prednisone. T l p ng l khong 60% vi thi gian iu tr trung bnh mt nm hoc hn. + Cc phc kt hp ca CA v FAC cng c hiu qu r rt. + Sau khi bnh khng p ng vi cc phc kt hp thuc ni trn na th phi dng n cc thuc khc. Cc thuc c th dng cho bnh nhn giai on cui l Taxol, Fluorouracil, Methotrexate, Vinblastine, Vincristine, Mitomycin C v Prednisone. c) iu tr phu thut : Trong giai on ny, phu thut khng ng vai tr quan trng. Trong mt s trng hp do khi Ung th ti tuyn v pht trin gy lot da, bi nhim... nh hng nhiu n sinh hot ca bnh nhn th c th ch nh m ct b v dn sch tm thi cc tn thng ti ch .