Tgp chi Tai Mui Hpng Vipt Nam -Volume (57-7). N°1 - March. 2012 - Ung thu lan ra ngodi tang thanh mdn
(ung thu h^ hpng, ung thu hai tdng hodc ba tang thanh qudn): lugng galectin-3 tdng so vdi nhdm ung thu chi khu trii d thanh mdn.
- Ung thu lan rdng: lugng gaIectin-3 tdng ty le vdi miic dd T (tir TI din T4).
- Ung thu di cdn hach cd rd ret (N2- N3): lugng galectin-3 tdng so vdi nhdm ung thu chi cd hach cd NI hodc chua di cdn hach cd
- Ung thu giai doan mupn (S3-S4):
lugng gatectin-3 Idng ty Ip vdi miic dp S (tir Sl din S4), trir giai doan S2 cd chi sd bdi mdu luong duong giai doan S1.
- Ung thu cd dp md hpc II hodc III (dp biet hda trung binh): lugng galectin- 3 tang so vdi nhdm ung thu cd dp md hpc I (dp biet hda cao) hodc do md hpc IV (dp biet hda thap).
TAI LIEU THAM KHAO
1. Ngd Ngpc Lien (2000) Ung thu thanh qudn. Gidn yeu tai mui hgng. Tap III.
NXB y hoc Hd Noi 197-204.
2. Barondes S.H. ct al. (1994) Galectins: structure and function of a large family of animal lectins. -/ Biol Chem 1994: 269: 20807-10.
3. Choufani G. et al. (1999) The levels of expression of galectin-1, galectin-3 and Thomsen-Friedenreich antigen and
their binding sites decrease as clinical aggressiveness increases in head and neck cancers. Cancer 1999. 86. 2353-63.
4. Delorge S et al. (2000) Correlation of galectin-3/galectin-3-binding sites with the differentiation status in head and neck squamous cell carcinomas.
Otolaryngol Head Neck Surg 2000: 122:
834-41.
5. Gillenwater A. ct al. (1996) Expression of galectins in head and neck squamous cell carcinoma. Head Neck 1996: 18: 422-32.
6. Krzeslak A. et al. (2004) Galectin-3 as a multifunctional protein. Cell Moi Biol Letters 2004; 9: 305-28.
1. Liu F.T. et al. (2002) Intracellular functions of galectins. Biochim Biophys Acta 2002; 1572:263-73.
8. Piantelli M. et al. (2002) Lack of expression of galectin-3 is associated with a poor outcome in node-negative patients with laryngeal squamous cell carcinoma. J Clin Oncol 2002; 20: 3850-6
9. Plzak J. et al. (2000) Endogenous lectins as probes to detect differentiation-dependent alterations in human squamous cell carcinomas of the oropharynx and larynx. Int J Moi Med 2000: 5: 369-72.
10. Takenaka Y. (2004) Galectin-3 and metastasis. Glycoconj J 2004; 19: 543-9.
NGHIEN ClTU PHl/OfNG PHAP DIEU TRI PHAU THUAT U NANG VA RO GIAP LU'dl
Le Minh Ky*, Nguyen Thj To Uyen**
TOM TAT
U nang va rd giap-Iuoi Id benh ly bam sinh kha thudng gdp trong chuyen ngdnh Tai Mui Hpng. Muc tieu nghien cihi; tim hieu phuong phdp diiu tri phdu thuat, budc
*BV Tai Mui Hpng TU"'
" Bd m6n TMH Dgi hpc Y Hd NOi Nh$n bdi 25/1/2012.- Duy^t in 30/1/2012
Tap chi Tai Mui Hpng Vipt Nam - Volume (57-7). N°1 - March. 2012
dau ddnh gid ty Ip tdi phat. Doi tup-ng va p h u a n g p h ^ p nghien ciiu: 47 bpnh nhan dugc chdn dodn va phau thuat dieu tri u nang vd rd gidp - ludi lai Bpnh vipn Tai Mui Hgng TW tir thdng 3/2004 den thdng 3/2005. Phutrng phdp nghien ciiu hdi ciiu, md td.
Ket q u a : Tudi benh nhan trung binh,Id 20,9 ± 17,1. Ty Ip nam/nit irong nghien ciru la xap \ i 2/1. Vi tri nang rd a \ung mdng-giap la hay gdp nhdt (78,8%), Ty Ip nang rd giap- ludi ham vdo mdi trudc \d mdi sau xuang mdng Id nhu nhau, Hau bet bpnh nhan cd dien bien sau md toi ('i|,4'"o), Sau 6 thang Ihco dui dd cd 3 Irong sd 34 bpnh nhan bi tdi phdi, chiim 8.S"« Kcl luini: Ty le tai phdt sau md ciia chiing tdi cdn khd cao, Cdn luan thu cdc thi iroTig phutmg phap phau thuat nang rd giap ludi cua Sisirunk.
TCr khoa: u nang. in gidp ludi S I ' M M . V i n
1'hc study on surgical managemeni of thyroglossal duct cyst.
Th\roglossal duel cyst was common in V,HV field. Objectives: to find out the surgical management and primary evaluation the recurrent rate of thyroglossal duel cyst.
Patients and methods: 47 patients with thyroglossal duct cyst were diagnosed and operated in Nalional I-N I hospital from Mar 2004 lo Mar 2005. This was retrospective study. Results the mean age was 20,9, the range of age was from 2 to 72. The site the most frequent of c\'si was ihyro-hyoid region (78,8%). The duels and cysis could attach 10 anterior or posterior lace of hyoid bone, with equal rate. The most of patients had favorable postoperalion. The recurrent rate alter 6 months follow up was 8,8%.
Conclusions: Sistrunk's operation was the treatment of choice, our recurrent rate was high, ll had lo respect the rules of Sislrunk's operation.
Ke>' words Thyroglossal duct cyst I. DAT VAN DE
U nang vd rd gidp-ludi Id benh ly bam sinh kha ihudng gap trong chuyen ngdnh Tai Mui Hgng.
Tir n5m 1920, dya tren nhumg nghien cim ve phdi thai hgc vung mang ciia Wenglowski, Stslrunk da khuyin cao viec cdt than xuang mdng vd phau tich phan tren xuang mong idi tan Id lit cua ddy ludi trong phau ihual dudng rd.
Nguyen idc phau thudt ndy da lam gidm hdn ly le tai phdt.
O Viet Nam, u nang vd rd gidp - ludi khd thudng gap, sd trudng hgp bi tdi phdt sau md cdn cao. chan doan de bi nham Ian, cd nhu-ng Irudng hgp trudc md chan dodn Id u nang gidp ludi nhung md ra lai la u nang da hay u md hay nghi ngd la tuyen gidp lac cho...
Chiing tdi lien hdnh nghien cuu de lai nghien cim phuang phdp dieu tri phau thudt nang vd rd gidp ludi vdi muc dich lim hieu phuong phap dieu iri phau thuat, budc dau danh gid ly le tdi phdt.
II. D 6 I T L O N * ; \ A P H I o N t ; P H A P N G H I E N c i V l '
2.1. Doi l u p n g nghien ciru
47 benh nhan dugc chan dodn va dieu Iri u nang va rd gidp - ludi tai Benh vien Tai Mui Hpng IW tir thdng 3/2004 d i n Ihdng 3/2005.
Tieu chuan lya chgn benh nhan:
Tat ca cac benh nhan dugc khdm vd chan dodn u nang hodc rd gidp - ludi.
Khdng phan biel gidi tinh, nghe nghiep, noi sdng.
Benh nhan da dugc phau ihuai lai BV Tai Mui Hpng trung uimg, cd hd so
Tgp chi Tai MDi Hpng Viet Nam - V o l u m e (57-7), N°1 - March. 2012 benh dn, cd phieu ghi each thirc phau
thuat rd rdng.
Tieu chuan loai Irii:
Benh nhan qud be dudi 2 ludi hodc cd benh ngi khoa ndng, chua dugc phau Ihuat. Cdc benh nhan cd chan dodn sau phau thudt chua ro rdng.
2.2. Phu-ffng phap nghien ciru III. KET QUA NGHIEN CUtl 3.1. Tuoi va gioi tinh
Bang 3 . 1 . PhSn b6 v^ gidi tinh vd tu6i
2.2.1. Phuong phdp: nghien ciru hdi ciiu Ihdng ke md la.
2.2.2. Cdc bu&c tien hdnh: khai thdc lien sir benh, Irieu chirng lam sdng, each thirc phau thuat, lap phicu theo ddi, khdm lai sau 3 thdng, sau 6 thang, 2.2.3. Xu ty sd li^u: theo chuong trinh EPI-INFO 4.0
TuAi Nam
NO'
Tong so
<10 9 19,14 8 17,02 17 36,17
11-20 8 17,02 1 2,13 9 19,15
21-30 5 10,64 4 8,51 9 19,15
31-40 4 8,51 2 4,26 6 12,77
41-50 2 4,26 1 2,13 3 6,38
>50 3 6,38 0 0 3 6,38
T6ng 290 66,00
154 34,04 548 100
Tudi vdo vien trung binh Id 20,9 ± 17,1. Benh nhan it ludi nhal la 2 tudi, nhieu ludi nhat Id 72 ludi.
Nhdm gap nhieu nhat Id lir 10 ludi trd xudng, sau dd ty le giam ddn.
Ty le nam/nu trong nghien ciiu la x ^ xi 2/1. Sy phan tich cd y nghia Ihdng ke (p < 0,01).
3.2. Vi tri cua u nang va ro giap luoi
Bang 3.2. Vj tri cua u nang vd rd gidp lu&i
GiOa L$ch phai L^ch trdi T6ng
%
Tren Xlfffng m o n g 4 1 0 6 10,6
Vung giap m o n g 32 2 3 37 78,8
ThU'g'ng i j c
4 1 0 5 10,6
Tong
40 4 3 47
%
85,1 8,5 6,4
100
Vi tri nang rd d viing mdng-giap la hay gap nhdt (78,8%).Vi tri Iren xuang mdng va thuong lic gap vdi ty le nhu nhau (10,6%). Khdng cd trudng hgp ndo nam d ddy ludi.
3.3. Vi tri ham cua nang rd giap-Iuoi vao than xu-ong mong
Bang 3.3. Vj Iri bdm cua nang rP gi^p-lu'6'i vdo IhSn xuong mPng
Vi tri giita cd la hay gdp nhat (85,1%). Mgt sd trudng hgp nang vd rd nam lech nhp sang phdi hodc trai (14,9%).
Tap chi Tai Mui Hong Vi?t Nam - Volume (57-7). N°1 - Inarch. 2012
Vj tri bam Tr§n xu'ong m6ng Viing m6ng-giap T h u v n g U'C T d r g
M$t tru'b'c 6 20 2 27 57.45%
iVI^t sau 0 17 3 20 47.55%
T i n g 5 37 5 47 100%
1 > le nang rd gidp-ludi bam v;i() mdt trudc vii mdi sau xuong mdng Id nhu nhau.
Tat ca 5 henh nhan co khdi u nang hay dircmg ro a tren xuong mdng deu bam vao mat trudc hodc inril inrtrc \;i bd tren xuong mdng,
3.4. Bien iliinig t n m g \ a .sau nio
Bdng 3.4. Tai bi^n sau md
D i n lu-u km
D^n luu ho
Kh6ng dan li^u
l o n g so
Nhi6m t r i i n g 0
2 4.25 0
2 4.25
Tu miiu 0
2 4.26 0
2 4.25
T6t 15 31.91 25 53.19 3 6.38 43 91.49
T i n g 15 31.91 29 61,17 3 6.38 47 100 Hau het benh nhdn cd dien bien sau md tdt (91,4%). Cd 2 benh nhdn bi nhiem iriing vet md vd 2 benh nhdn khac bi lu mau nhe, Ca 4 benh nhan nay deu dugc ddt dan luu hd. Nhdm ddt dan luu kin khdng xa\ ra lai bien gi,
3.5. Ty le till phdt
Bang 3.5. Ty Ip t^i phdt sau 6 thdng theo ddt
So b§nh nhan N=34
%
T i l p h i t 3 8.8
T5t 31 91,2 Chung tdi iicn hanh giri phieu theo
ddi cho benh nhdn de dieu tra linh hinh tdi phdt cua benh, Cd 38 benh nhdn d:i lien lac lai. Trong sd 38 benh nhan ndy chung tdi Igc dugc ^4 trudng hgp da md each day it nhdt 6 thang.
Nhu v^y, sau 6 ihang theo ddi da cd 3 trong sd 34 benh nhan bi lai phdi, chiem 8,8%.
IV. BAN LUAN 4.1. Tuoi va gidi tinh
Nghien cim cua chimg tdi cd 47 bpnh nhdn \ d i ly le nam/ nii a 2/1 (khdc bipt ndy la cd y nghTa Ihdng ke, p<0.01).
Tuy nhien Irong nghien ciiu ciia Allard vdi n ^ l 7 4 7 thi ty le nam/ nii«l/I[2].
Nhu vay, cd Ihe ty le ve gidi trong
20
Tap chi Tai MOi Hpng Viet Nam -Volume (57-7). N°1 - March, 2012 nghien ciru ciia chung tdi la chua Ihyc do
cd mdu cdn nhd.
Tudi trung binh ciia benh nhan khi tdi vien dieu In la 20,9 ± 17, be nhal Id 2 tudi vd ldn nhat la 72 ludi.
4.2. Vi tri u nang va ro gidp-ludi Benh ly u nang gidp-ludi cd the gap d bal ki vi tri nao Iren dudng gidp- ludi, lir lo ijt d dinh chir V ludi cho tdi thuy thdp cua tuyen gidp, Thdng thudng nd dugc chia lam 4 doan: d ddy ludi, tren xuong mdng( bao gdm ca dudi hdm), VLing mdng-giap (tir xuang mdng Idi bd dudi sun gidp) vd cudi cimg la doan thugng lie [2].
Chiing tdi khdng cd irudng hgp ndo u nang nam d ddy ludi, theo nhu ket qua ciia cdc lac gid khdc thi vi tri ndy cung il gap (thudng tir 0-3,3%). Vj iri tren xuong mdng ihudng gap lir 19-40%
[2] nhung cung cd lac gia chi gap 2,2%
[5], Irong nghien ciiu ciia chung tdi gdp vdi ti le 10,6%. Vi tri hay gap hon cd Id d vung mdng-giap, chiing tdi gdp 78,8%.
Trong khi dd, cac Idc gid khdc thudng gap lir 56,8-65,3%, tuy nhien su khdc biet ndy khdng cd y nghia Ihdng ke . Cdn vi tri thugng Ore cd li le lir 2,2-13%, chiing tdi gap 10,6% (5 benh nhan) 4.3. Vj tri bam cua u nang va ro vao than xwffng mong
U nang gidp-ludi cd the gdn tryc ti^p vdo xuong mdng hay bdm qua mpt thimg. Trong nghien ciiu ciia chiing tdi, sd u nang gidp-ludi bdm tryc tiep gap 2 Idn bam qua thimg.
Tren thyc le, chiing tdi thdy nhuTig khdi u nang vd dudng rd giap-Iudi nam tir xuong mdng Ird xudng cd ty le bam vdo mat trudc vd mdi sau xuong mdng xdp xi nhau (mat trudc: 48,6%, mat sau:
42,6%). Bihu nay cd ih^ iy giai bang hai
khd ndng: thir nhal la do khoi u nang vd dudng rd ndy dugc hinh thdnh d doan dudng giap-tudi Irudc khi dudng nay vdng ra sau xuong mdng; thir hai cd the Id do khdng phai Idt ca cdc trudng hgp dudng gidp-ludi deu vong vd bdm mdt each chdt che d mdt sau xuong mong,
Ngodi ra, vi Iri bdm cua dudng rd d than xuong mong cung khdng hoan loan giong nhau. Cd Idc gid cho rdng, phdn ldn dudng rd bam vdo mdng xuong nhung nd cung cd the ndm trong chat xuang ciia xuong mdng [2]. Trong nghien ciiu nay, chiing Idi khdng phdt hien dugc trudng hgp ndo Ihirng dudng rd gidp-ludi nam trong chat xuang cua thdn xuong mong,
Cd 1 benh nhan u nang gidp-ludi, khi phau thudl, ngodi khdi u nang va thimg chay tdi xuong mdng. cdn phat hien thdy mdt Ihimg thir 2 chay lir u nang tdi thuy thap cua tuyen gidp. Hinh dnh nay co dugc nhdc Idi Irong nghien cim ciia cac lac gid khdc, nd khang dinh dudng gidp-ludi dugc lao thdnh do sy di chuyen ciia luyen giap trong Ihdi ky bdo thai.
Phdn dudng rd trong ddy ludi ddi khi cd the nhin thdy trong phau Ihuat nhung ly le khdng cao. Trong nghien ciiu ndy, 9/47 trudng hgp chiem 19,2%
cd dudng rd trong ludi dugc phdt hien khi phau thuat.
4.4. Tai bien trong va sau mo Chdy mau sau md u nang vd rd giap ludi cd the gay tu mdu ldn gay chen ep vdo dudng Ihd, neu khdng xir tri kip ihdi benh nhdn cd the tir vong. Song, trong nghien cuu ndy chi cd 2 benh nhan bi tu mdu nhe d vung cd. Sau vdi ngdy dieu tri khdng sinh giam viem, bang ep, khdi mdu lu ndy ly tan md khdng can can thiep bang phau thuat.
Tap chi Tai Mui Hpng Vipt Nam - V o l u m e (57-7). N°1 - March. 2012 Trong sd 47 hcnh nhan dugc
nghien ciru con cd 2 hcnh nhan khdc bj nhiem Iriing vii mii nhe Sau khi laLli nhe mep \cl mo \';i n.iii hcl dich viem cimg \'(Vi \'icc diing khang sinh gKim
\njrii, vii mo diin dd sung nc.
C;i 4 benh nhfin n;iy {2 bpnh nhan l\i mau \.'i 2 bpnh nhan nhicm Itiing vet md) deu dugc dal dan luu ho Trong khi do, iihiTng bpnh nhan o nhom ddt dan lim km deu khdng cd tai hiOn Nhu \."iy. cd llii- ndi. dan luu kin dam bdo su dan luu lien luc \>i Jan luu nidi chieu nen nguy C(i til mdu \ a nhicm triing it hon
Ngoai ra. liong qua liinh mi>. ^.o mpt benh nhan bi nghi ngtr cd thiing niem mac ha hong, da dugc dal sonde trong 8 ngay, Sau khi riil simde bpnh nhan da dugc chup thyc qudn cd can quang nhung khdng phai hien dugc dutrng rd. Benh nhan ndy bi lai phdi dudi dang Id rd sau mo 10 ngay.
Kliniiy cd benh nhan ndo cd bieu hien suy giap cap sau md.
Khdng cd benh nhan nao bi tdn thuong than kinh ihanh quan tren sau md.
Tai bien nay cd the xay ra d thi cdl than xuong mong.
4.5. lai phat sau md
Tinh den nay, chung tdi co "^4 3S benh nhan dugc theo ddi sau md 6 thdng.
Ba trong idng sd 34 bpnh nhdn ndy dd bj tai phai dudi hinh thirc rd. Nhu \ a \ . chi sau 6 thang iheo ddi da cd 8,8% idi phdt.
Ty le nay la immg ddi cao so vdi cac tdc gia khdc [2|.
Sau khi phan tich nhung nguyen nhan co the dan tdi lai phat d nhdm benh nhan ndy, chimg toi thay cd 3 benh nhan deu bj bo qua viec lay dudng rd d ddy ludi; 1 benh nhdn sau khi cdl than xuong mdng, phau Ihual vien da d^ lai mdng
xuong vd 1 irudng hgp dc nguyen ca xuang mdng ciing mdng xuong.
Nhu v;iy. mdc dii u nang vd dudng ri) gidp-ludi chinh dd dugc lay di mpt cdch irgii vpn nhung vipc lay bd than xircmg mdng ciing mang xuong dong thai lay ho mgi phan trung ldm cua co ilay ludi tu xuong mdng tdi lo tit cung lal can thiet dc trdnh tdi phdi.
Do dicu kipn thdi gian ciia nghien ciru cd han nen.chiing tdi chi theo ddi sau mu 6 thdng. Nhmig neu ihdi gian theo dSi sail md tlai h(m {tir 2 nam trd len) thi ly le tdi phdt cd the sc cao hon nua.
Theo nghien cim ciia cac tdc gia khac ircn the gidi thi trudc ddy ly Ic tdi phat ciia hg cung rat cao nhimg sau khi dp dung phuong phdp md ciia Sisirunk Ihi ly li- tai phai dd gidm hdn xudng lir 0 di-ri i >'l..\2].
V. K K T L l ' A N
Qua nghien cim 47 benh nhdn u nang rd gidp-ludi, chiing tdi riit ra mpl sd kcl luan sau: Tudi benh nhan tmng binh la 20,9 ± 17,1. Ty le nam/nii trong nghien ciru la \ a p \i 2/1. Vi tri nang rod viing mdng-giap la hay gap nhat (78.8%).T> le nang rd gidp-ludi bdm vao mdt trudc \ a mdi sau xuong mdng Id nhu nhau. Hdu het bpnh nhan cd dien bien sau md tdt (91,4"o). Sau 6 thdng theo doi da cd 3 Irong sd 34 benh nhdn bi lai phat, chicm 8,8%
Ty Ip lai phdt sau md ciia chung loi cdn khd cao Nguyen nhan la chua thyc hipn day dii cac thi Irong phuang phdp phau Ihual nang rd gidp ludi cua Sisirunk.
TAI LIEUTIIAM KHAO
I Vu Vdn San (1989), Ludn van l6l nghipp bdc sy ndi tni Tai Mui Hpng, Truong Dgi hgc Y Hd Noi, Hd Ngi.
22
Tap chi Tai Mui Hpng Viet Nam -Volume (57-7). N°1 - March. 2012
2. Allard R.H.B. (1982), "Tliyroglossal patients witli Thyroglossal duct cyst", cyst". Head and Neck surgery S. pp. AJR, 164, 1489 - 1491.
'^''''-'^ 5. Sade J., Rosen C , (1968), 3. Hawkins D.B. cl al, (1982), "cyst of "Thyroglossal cyst and tracts: a the thyroglossal duct". Laryngoscope, 92, histological and histochemical slydy", 1254-1258 Am Otol Rhinol Laryngol. 77, 139-145.
4. Lim - Dunham J. E., Feinstein K.A., 6. Topf P. and all., (1988), "Vagaries Yousefzadeh D.K.et al, 1995, of thyroglossal duct cysts",
"Sonographic demonstration of a normal Laryngoscope 98: July. 740 - 742.
thyroid gland excludes ectopic thyroid in
NGHIEN CilXJ CAC VEU T O TIEN LlTpNG TRONG XA TRI PHOI Hpp HOA TRI UNG THU' HA HQNG - THANH QUAN
GIAI DOAN M U O N (HI, IVA,B MO)
Biii Cong Toan Nguyen Dinh Phiic TOM TAT
Nghien ciiu cac yeu to tien luong UTHH-TQ giai doan 111-lVB khong phau thuat duoc tren 60 benh nhari tai Benh vien K tir 2005 den 2008 chung toi nhan thky: 1. Cac yeu to tien lugng tot gom: tuoi duoi 45; chap h^nh diing lieu trinh di6u tri; chi s6 toan trang con tot (PS = 0; 1); u 6 giai doan khu tru; giai doan benh som hon; co nuoi duong qua xong da day va dap img vtyi dieu tn (p < 0,05). 2. Khi truyen dii chu ky hoa tri (thai gian, lieu lirgng, chu ky, xa dung lieu trinh) (76,7%) co dap ling dieu tri cao hon han so vcri chi xa tri don thuan voi 56,7% het trieu chimg; 55%) dap img hoan toan, dap img u 71,7%, hach 62,8%.
Tir khoa: ung thu ha hong - thanh quan
SUMMARY: STUDY ON PROGNOSIS FACTORS IN CONCURRENT CHEMORADIATION TREATMENT FOR ADVANCED HYPOPHARYNX CANCER (STAGE 111, IV A-B MO)
60 patients were recruited in a study on prognosis factors of unresectable stage III IV b MO hypopharynx cancer in K hospital from 2005-2008. New finding were follow: 1. Good prognosis factors included: age < 45years old; finished regimens, good performance status (PS = 0; 1); tumor was Tl, T2; earlier stage; gastrotomy and sensitive response with treatment (p < 0,05).2. After finish chemoradiotherapy (dose, time, cycle). 76.7% has good response which was much higer compared to radiation only; 56.7% symtom eradication; 55% complet response; 71.7% timior response; 62.8%
lymph node response.
Keys words: laryngo - hypopharyngeal cancer I. DAT VAN DE 1.B#nhvi#nK
2 Bai hoc Y HA N0i Ung thu ha hong-thanh quan Nh$n bii 10/2/2012. Duy$t in 20/2/2012 (UTHH-TQ) 14 benh dirng hang thll hai
