CHUYN UNG TH(TUMOR MARKERS)

DN BI I. DICH T HC. II. NGUN GC CA UNG TH. III. BNH HC PHN T. IV. TNH CHT C TRNG CA T BO C TNH. V. HNH THI HC. VI. C IM DI TRUYN. VII. MI TRNG V CH N UNG. VIII. K HIU TNM. IX. MT S CDUT 1. AFP. 2.CA 19 9. 3.CA 125. 4.CA 72 4. 5. CA 15-3. 6.PSA. 7. hCG v hCG 8.THYROGLOBULIN. 9. S LC MT VI CDUT KHC . 10. VAI TR CA PHC HP CC CDUT TRONG LM SNG. 11. CASE STUDY

I. DCH T HCUng th l nguyn nhn t vong ng hng th 2 sau bnh tim mch.

T l bnh ung th gia tng theo tui.

Ngoi ra yu t mi trng, thi quen n ung cng vi tnh trng kinh t x hi, tn gio cng nh hng n ung th.

M v cc nc pht trin, ung th chim khong 25% trng hp cht do mi nguyn nhn. Thng k hng nm th khong 0,5% dn s c chan on ung th.

i vi n ng trng thnh M, ung th hay gp l ung th tin lit tuyn (33% ca tt c cc loi ung th), ung th phi (13%), ung th i trc trng (10%), ung th bng quang (7%) v u hc t da (5%).

Nguyn nhn t vong do ung th phi hay gp nht (31%), ung th tin lit tuyt (10%), ung th i trc trng l (10%), ung th tu (5%) bnh ung th bch cu (4%)

i vi ph n trng thnh M, ung th v hay gp nht (32% ca tt c cc loi ung th), ung th phi (12%), ung th i trc trng (11%), ung th ni mc t cung (6%) v u lympho bo khng Hodgkin (4%).

Theo nguyn nhn t vong, ung th phi dn au (27% trong tong s cht do ung th), ung th v (15%), ung th trc trng (10%), ung th bung trng (6%) v ung th ty (6%)

II. NGUN GC CA UNG TH

Phn chia t bo (tng sinh) l qu trnh sinh l xy ra trong nhng iu kin nht nh hu ht cc m trong c th sinh vt a bo. Bnh thng s cn bng gia tc ca qu trnh tng sinh v qu trnh cht ca t bo c iu ha mt cch cht ch m bo cho tnh ton vn ca c quan v m.

Khi cc t bo xy ra nhng t bin trong DNA, chng c th ph v c ch iu khin ny v dn n ung th.

III. BNH HC PHN T

S tng sinh khng kim sot v thng l nhanh chng ca t bo s to thnh cc khi u lnh tnh hay khi u c tnh (ung th).

Nhng khi u lnh tnh khng lan trn n nhng ni khc trong c th hay xm ln vo cc m khc, v chng him khi e da n tnh mng tr khi chng chn p n cc cu trc sng cn.

Cc khi u c tnh c th xm ln vo cc c quan khc, lan n nhng ni xa hn (di cn) v tr nn e da n tnh mng.

IV. CC TNH CHT C TRNG CA T BO C TNH:Trnh c apoptosis (cht theo chng trnh) Kh nng pht trin v hn (bt t) T cung cp cc yu t pht trin Khng nhy cm vi cc yu t chng tng sinh Tc phn bo gia tng Thay i kh nng bit ha t bo Khng c kh nng c ch tip xc Kh nng xm ln m xung quanh Kh nng di cn n ni xa Kh nng tng sinh mch mu

V. HNH THI HC

VI. C IM DI TRUYN Mt s t bin gene BRCA1 v BRCA2 lin quan n tng nguy c ung th v v ung th bung trng Cc khi u ca cc c quan ni tit trong bnh a u tuyn ni tit (multiple endocrine neoplasia : MEN th 1, 2a, 2b) Hi chng Li-Fraumeni (sarcoma xng, ung th v, sarcoma m mm, u no) do t bin ca p53 Hi chng Turcot (u no v polype i trng) Bnh polype tuyn gia nh l mt t bin di truyn trong gene APC dan n pht trin sm ung th i trng U nguyn bo vng mc tr em l ung th di truyn

VII. MI TRNG V CH N UNG

VIII. K HIU TNM Cc nh y hc c th nh gi khi u da trn 3 yu t: Mc lan rng ca khi u, k hiu T ( tumor).Tnh trng hch vng, k hiu N ( node).Mc lan xa ca khi u, k hiu M (metastasis).

u im ca cc Tumor markerCc Tumor marker c nhng u im sau: - c hiu cho ung th (v tr khu tr). - Nng Tumor marker t l vi th tch khi u. - Pht hin c t giai on sm ca bnh. - Xc nh c mt cch chnh xc nng Tumor marker.

chn on bnh ung th, c th s dng phng php vt l, phng php gii phau bnh v phng php ha sinh thng qua vic xc nh du n ung th Tumor marker. Mi phng php c u v nhc im ring. V d phng php gii phu bnh cung cp cho chng ta thng tin "vng" v khi u, nhng hn ch v mt tm l, au khi chc ht sinh thit. Phng php ha sinh enzym-min dch xc nh chnh xc cc tumor marker, ch cn ly mu hoc nc tiu xt nghim de hn, cng cho chnh xc bn cht bnh ung th m khng gy au nhiu cho bnh nhn.

Du hiu v triu chngTriu chng ti ch: cc khi u bt thng hay ph n, chy mu (hemorrhage), au v/hoc lot (ulcer). Chn p vo m xung quanh c th gy ra cc triu chng nh vng da. Triu chng ca di cn (lan trn): hch bch huyt ln ln, ho, ho ra mu, gan to, au xng, gy xng nhng xng b tn thng v cc triu chng thn kinh. au c th gp ung th giai on tin trin, nhng thng thng khng phi l triu chng au tin. Triu chng ton thn: st cn, chn n v suy mn, tit nhiu m hi ( m hi trm), thiu mu v cc hoi chng cn u c hiu, l tnh trng c bit c gy ra bi ung th ang hot ng, chng hn nh huyt khi (thrombosis) hay thay i ni tit t.

Cc loi ung th

Ung th c th c phn loi da theo tnh cht gii phu bnh hoc theo c quan b tn thng.

Cc t bo ung th trong mt khi u (bao gm c t bo di cn) u xut pht t mt t bo duy nht phn chia m thnh. Do mt bnh ung th c th c phn loi theo loi t bo khi pht v theo v tr ca t bo . Tuy nhin, trong nhiu trng hp, ngi ta khng xc nh c khi u nguyn pht.

Ung th biu m (carcinoma) c ngun gc t t bo biu m (TD: ng tiu ha hay tuyn tiu ho).

Bnh l huyt hc c tnh (hematological malignancy): bnh bch cu (leukemia),u lympho bo (lymphoma), xut pht t mu v ty xng.

Ung th m lin kt (sarcoma) l nhm ung th xut pht t m lin kt, xng hay c.

U hc t do ri lon ca t bo sc t.

U qui bt ngun t cc t bo mm.

IX.MT S CDUT

S DUNG CAC XET NGHIEM TRONG CHAN OAN:

Colon: CEA (+++) + CA 19-9 (++)Pancreas: CEA (+) + CA 19-9 (+++)Stomach: CEA (++) + CA 19-9 (+) + CA 72-4 (+++)Esophagus: CEA (+) + SCC (+)Live (hepatocellular cancer: HCC): AFP (+++)Biliary tract: CA 19-9 (+++)Breast: CEA (+++) + CA 15-3 (+++)Ovary: CA 72-4 (++) + CA 125 (+++)Cervix: CEA (++) + SCC (+++)Chorion: hCG (+++)Lung SCLC: NSE (+++) + CYPRA 21-1 (++)Lung NSCLC: CEA (+) + CYPRA 21-1 (+++)Germ cell: AFP (+++) + hCG (+++)Prostate: PSA (+++)Bladder: CYPRA 21-1 (+) + TPA (+)Thyroid: CEA (+) + hTG (+++)C-cell: CEA (+) + Calcitonin (+++)

1. AFP (ALPHA-FETOPROTEIN) CH NH : Tuyt i :Nghi ng ung th t bo gan.U t bo mm.Theo di sau iu tr phu thut hay ha tr liu bnh u gan, t bo mm. Tng i : - Theo di bnh nhn x gan ung th ha, u t bo mm. - Theo di bnh nhn sau iu tr ct b u tinh hon. Tr s i chiu : < 10g/l.

NGHA LM SNG AFP c th tng thong qua hoc ko di trn bnh nhn b x gan. T 10 20% bnh nhn x gan c AFP tng cao trn mc sinh l .17% dao ng trong khang 15 100 g/l, 2% bnh nhn c [AFP] < 500 g/l v 1% cao hn 500 g/l. Nng AFP tng thong qua trong vim gan cp, man tnh.

Nng AFP tng thong qua trong vim gan cp, mn tnh.

Trong vim gan cp, c mi tng quan gi men gan v AFP. Men gan tng ti a (giai on hoi t) sau khi AFP tng n nh (giai an ti sinh) khong 2 tun.

Men gan tng ti a (giai on hoi t) sau khi AFP tng n nh (giai an ti sinh) khong 2 tun.

Theo di din tin ca bnh: Cng vi khi u lan rng, nng AFP cng tng theo, dao ng t 100 - 1000g/l. Tuy nhin, trong thi k u gan giai an cui, AFP khng tng xng vi tnh trng khi u do ri lon chuyn ha. AFP c th gim trc khi u gan chuyn sang thi k cui.

Tin lng tt khi half-life < 5 ngy.

i vi nhng bnh nhn c half-life AFP > 7 ngy, hCG > 3 ngy sau 2 chu k ha tr liu c t l sng thp hn.

- Khi AFP > 500 g/ml th t l chn on ung th gan rt cao.

- Xt nghim AFP rt c ch trong vic theo di bnh nhn nguy c cao: x gan, HbsAg (+). Nhng bnh gan c tng AFP, nguy c tin n ung th rt cao, v tin lng d dt sau 5 nm theo di.

- Trong bnh gan mn theo di thy AFP tng cao, nht l ln sau cao hn ln trc trong thi gian 1- 2 tun th rt gi ung th ha.

Mt s du n ung th gan khc

Decarboxy prothrombin (DCP)L mt prothrombin bt thng, do t bo ung th gan tit ra, c nhy tng ng AFP nhng rt c hiu (nu khng c thiu vitamin K).

Nm 1984, Liebman v cng s pht hin nng DCP huyt thanh tng cao nhng bnh nhn UTBMTBG.

Bnh thng, prothrombin c carboxy ha trong t bo gan, di tc dng ca men carboxylase ph thuc vitamin K.

Trong ung th gan do thiu men ny, gy tit ra trong huyt thanh mt prothrombin bt thng l DCP.

DCP c nhy khong 70% v c hiu l 100% trong chn on UTBMTBG, nhng ch t ra u vit hn AFP nhng bnh nhn c khi u trn 5 cm

Tr s bnh thng: < 16mU/ml.

Trong ung th gan, DCP > 200mU/ml 75% trng hp.

Alpha-fructose(AFU)Alpha-fructose(AFU) l mt men do lysosom tit ra > 400 nmol/ml/h; nhy 65%, c hiu 90%.

AFU t ra km c hiu nhng bnh nhn Chu Phi da en b UTBMTBG v c hiu km hn so vi AFP. nh lng ng thi AFP v AFU th gip lm gim 5,5-13% cc trng hp m tnh gi ca AFP. Nh vy, AFU c th c ch khi phi hp vi AFP nhng vng tn sut UTBMTBG thp

GGT gia tng trong 70 100% trng hp ung th gan, nhng khng hon ton c hiu. Bnh thng < 35 U/ml.

Ferritin cng gia tng trong ung th gan nhng nhy thp v t c hiu.

Phosphatase kim gia tng nhiu, nht l khi c s bnh thng nghch l yu t V d c x gan, l ieu rt gi .

HI CHNG CN UNG THa HC: chim 3 12%.

Tng canxi mu

H ng huyt.

Hi chng carcinoid v tiu ra porphyrin.

2. CA 19 9 - C gi tr trong chn on sm, theo di iu tr v pht hin khi u ti pht trn bnh nhn u ty, gan mt, d dy. - Tr s i chiu : 37 U/ml.

NGHA LM SNG : - Nng CA 19-9 mc 100 U/ml chn on phn bit ung th ty vi mt s bnh l ty lnh tnh khc trn bnh nhn st cn, au bng. Theo , nhy l 62%, chuyn l 97%.

Ung th ty : Nng v t l bt thng CA 19-9 c lin quan n :V tr u trn ty: mc quyt nh: 37 U/ml; u ty 80%; thn, ui ty: 57%. lan rng ca khi u; mc quyt nh : 120U/ml. T2/3 33%; T + N1 71%, TN + M1 85%; Kch thc khi u : mc quyt nh 37U/ml : 6cm 100%.

Ung th gan v ng mt : Trong ung thu gan v ng mt nhy ca CA 19-9 t 22 51%; trong khi ung th ti mt l 55 79%.

Ung th d dy Trong ung th d dy, CA 19-9 c nhy l 26 60% .

Khi 2 xt nghim CA 19-9, CEA cng c tin hnh th nhy c th tng ln gp i.

Vic phi hp CEA, CA 19-9 c th l gi tr tin lng kh nng sng cn c lp trn bnh nhn u d dy, ngoi nhng th thut xm ln, di cn gan, mng bng, giai an ung th.

Ung th i trc trng Trong ung th i trc trng nhy ca CA 19-9 l 18 58%, ty thuc vo giai an ( Dukes A 0 7%; B 17%; C 47%; D 75% ).

Hn na, ngoi giai on ca khi u th gi tr CA 19-9 hu phu c gi tr tin lng c lp kh nng sng cn ca bnh nhn (mc quyt nh 37 U/ml : t l sng sau 3 nm l 61% so vi 90%).

Theo di din tin bnh Cng nh nhng cht CDUT khc, CA 19-9 l du n tt trong theo di din tin bnh khi c o lp li nhiu ln ti cc thi im khc nhau, bi v gi tr bnh thng ca CDUT khng loi tr c bnh c tnh cng nh bnh lnh tnh.

Cn lm lai xt nghim ny sau 2 tun Bnh l c tnh nu khng iu tr, CA 19-9 s tng t t, i vi bnh lnh tnh, du cho tng thong qua hay ko di, thng thng < 200 U/ml.c trng hp > 1000 U/ml.

Trong ung th ty, gan mt, d dy v i trc trng gi tr CA 19-9 c lin quan cht ch vi din tin lm sng, cng vi iu tr phu thut, ha tr, x tr.

Din tin lm sng c th:Tr v gi tr bnh thng trong vng 2 4 tun sau phu thut ct b khi u (giai on 1).Khi iu tr bng cch gim au, c th CA 19-9 gim t, hay thong qua.CA 19-9 tng cao trong trng hp khi u ti pht, bnh tin trin.

Theo di lin tc nng CA 19-9, c th thy c gi tr ca CDUT ny nh sau :Ung th d dy ( nhy 38 70%, chuyn 89 91 %, chnh xc l 83%).Trong ung th i trc trng ( nhy 53 73%, chuyn 91 94%, chnh xc l 80%).

CA 19-9 c th nh gi hiu qu ca liu php ha tr; n c th ch ra cn thit phi thay i ch iu tr mi hoc kt thc mt liu php iu tr.

3. CA 125CH NH :Tuyt i : - Nghi ng u bung trng. - Theo di iu tr v din tin bnh u bung trng.Tng i : nghi ng ung th ty.Tr s i chiu : < 35 U/ml.

NGHA LM SNG Bnh l lnh tnh : CA 125 tng trong mt s trng hp : vim phn ph ( 17 25% > 65 U/ml), vim vng chu, vim phc mc ( 59% > 65 U/ml), tt rut, bnh l d dy rut lnh tnh ( 2 8% > 65U/ml).

Ung th bung trng :C khong 15/100,000 ph n mc bnh ung th bung trng mi nm, nhy ca CA 125 t 82 96% (mc quyt nh 35U/ml) v chuyn 74 78% (mc quyt nh l 65 U/ml).

Mt t l bnh ton b ung th bung trng l 40%, th gi tr tin on dng nh sau : 91% cho tt c cc nhm bnh.93% cho bnh lnh tnh bung trng.

Gi tr tin on m nh sau :85% cc bnh khc.68% bnh lnh tnh.

Mc quyt nh 35 U/ml rt c hiu qu trong chn on phn bit gia u lnh, u c bung trng, cng vi thm khm lm sng vng chu, siu m.

Trong ung th bung trng, CA125 tng nh sau :Trong giai on sm (FiGO I II) 44 60% (mc ct 65U/ml).Giai on III IV tng 78 100% trng hp.U khc di cn bung trng ch tng 30% trng hp. Mi quan h gia CA125 v khi u:

CA 125 tin phu :Xt nghim ny c ngha tin lng trong ung th biu m bung trng. Ch s ny tng nh trong giai an sm, khi u nh, p ng tt vi iu tr, t l ti pht thp. Tri li, CA 125 tng cao, chng t bnh chuyn sang giai on mun, p ng km vi ha tr.

Lin quan gia CA 125 v din tin bnh :Sau khi phu thut hoc ha tr liu, nng CA 125 huyt thanh c quan h cht ch vi din tin ca bnh trong 87 94% trng hp ung th bung trng.

Trn bnh nhn sau khi phu thut khong 3 thng m CA 125 vn cao, chng t khi u ct b khng ht, cn li trn 1 cm.

i vi bnh sang giai an III/IV, sau ln ha tr u tin cn xc nh halflife ca CA 125, v n c ngha tin lng kh nng sng cn ca bnh nhn. Nu halflife < 20 ngy th tin lng tt, 20 40 ngy : trung bnh, > 40 ngy tin lng xu.

Sau 2 nm theo di, mt s tc gi nhn thy t l sng st theo th t l 76%; 48%; 0%. Do , chng ta nn lm xt nghim ny sau khi ha tr 1 thng.

Ung th d dy, rut : nhy nh sau: ung th ty 45 79% (mc quyt nh 35U/ml); di cn gan 70% (mc quyt nh 65 U/ml); u gan 40 77% (mc quyt nh 35/65 U/ml); ung th mt 46% (mc quyt nh 35 U/ml); ung th i trc trng 20 39% (mc quyt nh 35 U/ml). CA 125 c lin quan cht ch vi giai an ca khi u, c bit nht l ung th ty.

4. CA 72 4CH NH :Tuyt i : - Theo di hiu qu iu tr, din tin bnh ung th d dy.Tng i : - La chn th yu trong ung th bung trng.

NGHA LM SNG Bnh lnh tnh : Nng CA 72-4 c th tng trong mt s bnh l sau : vim ty (3%), x gan (4%), bnh phi (17 19%), bnh thp (21%).

Ung th d dy :Ph thuc vo giai an ca bnh, ch ra nhng t l dng tnh nh sau (mc quyt nh 6 u/ml) khi so vi CA 19-9 (mc quyt nh 37 U/ml) v CEA (mc quyt nh 5 ng/ml) l :11/33/0% ( giai on IA ), 20/20/13% (IB), 13/6/19% (II), 46/42/25% (IIIA), 41/28/21% (IIIB), 58/42/37% (IV) v 56/32/11% trong trng hp ung th ti pht.

Trong thi k hu phu, CA 72-4 s tr v gi tr bnh thng trong khong 1 2 tun, trong khi 70% trng hp ung th ti pht (CA 19-9 l 50%, CEA l 20%), chng tng trc hoc cng lc khi pht hin trn lm sng. Khi kt hp nhiu loi CDUT th nhy s tng ln nhiu; nhy ca CA 72-4 l 42% nhng khi kt hp vi CA 19-9 th nhy ca chn on tng n 57% trong khi cng vi CEA nhy ch tng 51%.

Ung th i trc trng : nhy ca CDUT ny khong 20 41%. C mi tng quan gia giai an ung th (theo Dukes) v t l chn on dng tnh ca CA 72-4 (mc quyt nh 4/6 U/ml) so vi CEA (5ng/ml), nh sau : 3 29% (A), 30 31% (B), 22 53% (C), 55 70% (D).Sau phu thut ct b khi u, CA 72-4 tr v tr s bnh thng trong khong 18 ngy. Khi kt hp vi CEA, nhay tng t 43% n 60% i vi chn on ung th nguyn pht, v t 78% n 87% i vi pht hin ung th ti pht.

Ung th bung trng : nhy khong 47 80% vi t l cao hn giai an III IV (56%) so vi giai an sm I-II. chuyn l 97%.

5. CA 15-3L thng s rt hu ch trong vic theo di ung th v di cn.Khng thch hp trong sng lc hoc chn on v nhy thp.Ch nh: Theo di hiu qu iu tr v din tin bnh ung th vTr s i chiu: 40 U/ml.

NGHA LM SNGBnh lnh tnh: Nng CA 15-3 tng: + Nhim HIV ( > 50%). + Vim gan man ( 5%). + Vim ph qun (15%). + Mt s bnh l lnh tnh khc: gan, ty, thp, lao (3.3% > 40 U/ml).

Bnh l c tnhUng th v- nhy ph thuc vo giai a ca bnh.

- Trc phu thut : 19 22%.

- 32% giai an M0 (mc quyt nh 50 U/ml).

- 54 91% trong ung th v di cn.

Tng quan gia CA 15-3 v kch thc khi uT l chn on dng: 4-16% (I), 13-54% (II), 65% (III), 54-91% (IV).14-23% (T1/2), 27-86%(T3/4) v 22% (khng di cn hch); 38% (di cn hch).

Trong ung th v di cn, nng CA 15-3 ph thuc vo v tr di cn.Di cn da c nhy thp.Di cn gan cao nht, CA 15-3 trung v: 54U/ml; (45% > 50 U/ml).a di cn (trung v 93 U/ml)

Tng quan gia CA 15-3 vi din tin bnhC th pht hin ung th ti pht vi nhy 45-77%; chuyn 94-98%; gi tr tin on dng 41-92%.Trong trng hp ung th v di cn v ang c iu tr, CA 15-3 tng hoc gim > 25%, s c 75-94% trng hp bnh tin trin, 72-93% p ng vi iu tr

CA 15-3 v CEATrong ung th v CA 15-3 tt hn CEA.Khi phi hp 2 CDUT trn, nhy 40/82%, chuyn 87% rt hu dng trong mt s trng hp ung th v di cn.

6. PSACH NH : - Sng lc nhng ngi n ng trn 50 tui c ung th TLT khng triu trng. - Theo di sau iu tr v din tin lm sng trn bnh nhn ung th TLT.

TR S I CHIU : 4 g/l.

NGHA LM SNG Bnh l lnh tnh : PSA tng trong trng hp ph i TLT lnh tnh, ph thuc vo tui, mc ph i vi tn sut 21 86% dao ng t 4 - 10 g/l; khong 25% > 10 g/l. Ngoi ra, TLT b vim hay nhi mu, CDUT ny cng s tng.

Ung th TLT : PSA cng vi vic thm khm trc trng lm tng kh nng pht hin ung th TLT ( t 1,3-1,7% n 2,2-2,6%). S dng PSA nh l mt test sng lc c th pht hin c 3% trng hp ung th TLT.

Nu kt hp khm lm sng v PSA th gi tr tin on dng l 50% v nhy cng tng cao hn so vi PSA n thun (20%) hoc thm trc trng (10%).

Mt nghin cu cho kt qu nh sau: 57% ung th TLT giai on mun c pht hin khm bng tay, trong khi ch c 37% pht hin bi PSA sng lc, v 27% l PSA nh k. Tuy nhin, c n 70 80% trng hp PSA tng trong khong 4 10 g/l khng mc bnh ung th TLT. Do ch s dng PSA m khng khm lm sng hay siu m ng trc trng c th b st 20 30% trng hp ung th TLT.

tng tc dng ca PSA trong vic sng lc ung th TLT, c bit khi gi tr trong khong 4-10 g/l, cch tip cn sau y rt c li chn on phn bit gia ph i TLT lnh tnh v ung th : a. Tnh t s PSA vi th tch TLT. b. Khi PSA tng 0,7 hay 0,8 g/l/nm th c kh nng 70% trng hp b ung th TLT vi nhy l 90% v chuyn 90 100%. c. Free PSA hay Free PSA/totalPSA

C th d on giai on ca bnh da trn nng PSA. Khi ung th TLT ch di cn, kh nng chn on ph thuc vo PSA nh sau : 75% ( 10 g/l) v 7% ( > 30 g/l). Khi PSA tng rt cao, chng t khi u khng cn gii hn c quan na; khi PSA > 20 g/l khng cn kh nng ct b. Mt cuc iu tra ch ra rng 70% bnh nhn ung th c PSA < 2 g/l ch gii hn c quan, trong khi PSA> 50 g/l th d c di cn hch vng chu.

Ngoi ra, PSA cn c th d on kh nng thnh cng ca x tr ln u. Theo kt qu mt nghin cu PSA trc iu tr v giai an ung th c tng quan vi kh nng ung th ti pht, mc PSA > 13 g/l, OR 4.26. Cng lc nu t trng PSA > 0.3 g/l c th d bo s tht bi vi x tr.

Sau khi ct b TLT bng sng radial, PSA c nng rt thp trong mu trong khong thi gian 3 6 thng, tng ng Half-life 2-3 ngy. Nu trn mc ny, chng t khi u cn st li.

Thm vo , PSA v liu php hormone cng c mi tng quan vi nhau. Mt nghin cu khong 24 thng cho thy 9% BN khng o c PSA trong khi 22% BN c PSA 2.5 g/l; 56% > 20 g/l; 15% > 100 g/l. PSA gim tng i hay tuyt i sau 3-6 thng l du hiu thnh cng ca iu tr.

p ng vi tr liu hormone rt quan trng trn bnh nhn sau phu thut c PSA < 4 g/l, trong khi gia tng PSA vi half-life 7.3 5 thng chng t bnh tin trin nng hn.

MT S VN THM V PSAMc tng hng nm ca PSA l 0,04 g/l, khc bit i vi cc mc bch phn v : 2,5 ( 40 49 tui ); 3.5 ( 50 59 tui ); 4.5 ( 60 69 tui ) v 6.5 ( 70 79 tui ). Half-life ca PSA ( tc gim sau phu thut ct b khi u ) l 2.2 0.8 ngy hoc 3.2 0.1 ngy.

Sau khi thm khm trc trng, PSA c th tng khong 0.5g/l trong trng hp PSA < 4 g/l. Ngoi ra, massage TLT lm tng 1.9 ln, cng nh ct TLT qua ng niu o, hay sinh thit qua ng trc trng. D bt k nguyn nhn no, half-life tr v bnh thng sau 3-6 tun.

7. hCG (human chorionic gonadotropin) v hCG hCG v hCG c vai tr quan trng trong chn on, theo di bnh nhn c ung th t bo mm.Tr s i chiu :< 5 UI/l

hCG l hormone thai nghn do cc nguyn bo nui tit ra, nng hCG tng cao chng t c s tng sinh mnh ca cc nguyn bo nui.

84% carcinoma m nui dng tnh vi hCG.

Carcinoma m nui l mt u t bo mm do cc t bo hp bo nui tit ra. N xy ra ph n, ch yu nh cc nguyn bo nui nhau thai v nam gii nh cc u tinh hon khng phi seminoma.

Cc t bo u bnh nhn bc l vi du n hCG, c bit cc hp bo nui dng tnh mnh vi hCG.

8. THYROGLOBULIN CH NH : - Theo di ung th tuyn gip sau khi phu thut v iu tr iode phng x. - Vim gip tc nghn. Tr s i chiu : < 50 g/l. Thyroglobulin l glycoprotein c tng hp trong t bo gip. Tng thyroglobulin l du hiu quan trng trong ung th gip bit ha

Test chn on ung th gipTest Pentagastrine:Chch TM trong vng 3 pht vi 0.5g/kg cht Pentagastrine ( Peptavlon ) ha trong 5ml mui ng trng.Ly mu vo cc thi im -5;0;3 v 5 pht nh lng calcitonine.Bnh thng: 10 30 pg/ml.Trng hp nghi ng: 30 100 pg/ml.Ung th ty gip trng : 100 pg/ml.

Cc lai ung th gipUng th biu m dng nh.

Ung th biu m dng nang.

Ung th t bo Hurthle.

Ung th ty gip trng.

Ung th biu m gip th khng bit ha.

U lympho.

9. S LC MT VI CDUT KHC 2-microglobulin: l cht ch im trong bnh a u ty, leucemia dng lympho mn, u lympho c tnh. Tr s bnh thng < 2g/ml.Bladder tumor antigen ( BTA ): l cht ch im trong ung th bng quang. Test dng tnh khi c BTA xut hin trong nc tiu.CA27-29: ch im trong ung th v. Tr s bnh thng: 38-40U/ml.Calcitonin: l cht ch im trong ung th tuyn gip th ty.

Chromogranin A (CgA): l cht ch im trong u nguyn bo thn kinh, ung th phi t bo nh v cc khi u dng carcinom. Tr s bnh thng :< 76 ng/ml.Lipid associated sialic acid in plasma ( LASA-P): ch im trong ung th bung trng v mt s lai ung th khc.NMP22: ch im trong ung th bng quang, c ngha bnh l khi > 10U/ml nc tiu.TA-90: ch im trong ung th v.

10. VAI TR CA PHC HP CC CDUT TRONG LM SNG

- Ung th i trng: CEA n c cho nhy 52%, khi phi hp 5 CDUT: CEA, 2 protein (AAG, CRP) v 2 isoenzym (CKM2,FHAP) nhy ti 96%.- Ung th ty: CA 19-9 c nhy khong 78%, khi phi hp mt s CDUT khc :DU-PAN2 hoc vi CA125 th nhy tng tng ng: 95% v 97%.- Ung th phi: CEA, NSE, CK-BB nhy ti 84%.- Ung th v: CA 15-3 nhy khong 83%, khi kt hp 3 CDUT: CA 15-3, CAM 26, CAM 29 cho nhy cao hn, 96%.- Ung th bung trng: CA125 n c co nhy 80%, khi kt hp CA125, TPA, ferritin, IAP cho nhy 100%.

Nng ch im khi u bnh nhn ung th

S DUNG CAC XET NGHIEM TRONG CHAN OAN:

- Colon: CEA (+++) va CA 19-9 (++)- Pancreas: CEA (+) va CA 19-9 (+++)- Stomach: CEA (++) , CA 19-9 (+) va CA 72-4 (+++)- Esophagus: CEA (+) va SCC (+)- Live (hepatocellular cancer: HCC): AFP (+++)- Biliary tract: CA 19-9 (+++)- Breast: CEA (+++) va CA 15-3 (+++)- Ovary: CA 72-4 (++) va CA 125 (+++)- Cervix: CEA (++) va SCC (+++)- Chorion: hCG (+++)- Lung SCLC: NSE (+++) va CYPRA 21-1 (++)- Lung NSCLC: CEA (+) CYPRA 21-1 (+++)- Germ cell: AFP (+++) va hCG (+++)- Prostate: PSA (+++)- Bladder: CYPRA 21-1 (+) va TPA (+)- Thyroid: CEA (+) va hTG (+++)- C-cell: CEA (+) va Calcitonin (+++)

CASE 1: Nhn mt trng hp carcinoma m nui nguyn pht phiBnh nhn n 37 tui, ho ra mu 5 ngy trc khi nhp vin,khng au ngc. Khm lm sng ph khoa khng pht hin g bt thng.

Hnh nh hc : - X quang phi : bn tri c mt m m. - CT scan : h phn thy 8 phi tri c mt khi u kch thc 3cm, b khng u,

Siu m : bng v phn ph bnh thng.

Xt nghimSHMD : hCG >1000U/l.

CTM : bnh thng.

Chc nng phi trong gii hn bnh thng.

Bn lunKt qu xt nghim hCG cao trong mu trn bnh nhn ho ra mu, dn ti nghi ng carcinoma m nui phi.

Tuy nhin, hu ht cc trng hp bo co bnh nhn thng i khm mun.

Kt qu test th thai nc tiu dng tnh ch mt vi pht, nhanh chng cho ta ch dn rt r rng trong chn on phn bit tn thng phi.

CASE 2: Nhn mt trng hp bu qui gip c tnh ca bung trngBnh nhn n 69 tui , PARA 6006, vo vin vi l do au bng vng h v.

Khm lm sng : vng chu c bu khong 7cm, di ng.

Cc c quan khc khng pht hin bt thng.

Cn lm sngCA 125 : 74.23 U/ml.

hCG, AFP trong gii hn bnh thng.

Siu m: thy cnh tri t cung c sang thng dng nang, kch thc 11x8 cm, b u, dch kh ng nht.

Chn on sau cng : bu qui gip c tnh bung trng.

Case 3Bn nam 45 tui vo vin v au h sn phi.

Bnh s: bnh pht cch nhp vin 10 ngy, bn t ngt st cao lin tc + au h sn phi, lan vai phi, ra sau lng, st cn 4kg/10 ngy.

Khm lm sng: M: 88l/p; HA: 120/70 mmHg; To: 37.5; cn nng: 49kg.Phi: APB gim y phi phi, khng nghe rales.Bng: Gan to 5cm di HS(p), b t, nhn, n au; rung gan, n k sn +.Tin s: ht thuc l > 1gi/ngy/>30 nm, ung ru > 20 nm.

Cn lm sngCTM : BC: 13050/mm3 ( N: 76,9%; L: 12%; E: 5,5% ), HC: 3,67 tr/mm3; TC : 600000/mm3.

Sinh ha: glycemia: 76mg%; AFP: 125ng/ml; BUN : 19 mg%; Cre: 0,9 mg%.

VS: bnh thng.

Bn lunK gan abces ha thng chc m c mu vng do bi nhim vi trng t ng rut.VS tng cao l du hiu quan trng trong chn on Abces gan.Tuy nhin trn bn ny, VS khng tng khng ch l abces n thun na.Ngoi ra, AFP tng.K gan t gy trn dch mng phoi (P) phn ng, nhng abces gan thng gy trn dch mng phoi (P) phn ng.

: K gan abces ha.

: K gan abces ha.

Trn bn c tin s nghin ru nhiu nm ( thng trn 10 nm ), nn lm thm AFP xem c b ung th hay khng.