DANH GIA VAI TRO CUA FDG PET/CT TRONG CHAN DOAN BENH UNG THU" PHOI KHONG TE BAO NHO
MAI TRONG KHOA, T R A N DINH H A , T R A N H A I BINH, NGUYEN THANH CHUONG, LE CHINH DAI, VU HUtJ KHIEM, VUONG NGOC DLTONG, NGUYEN QUANG HUNG, T R A N NGOC H A I , PHAM VAN T H A I , NGO T R U I N G SON, PHAM C A M P H L T O N G vd CS ....
(Trung tdm Y hoc hgt nhdn & Ung budu, Binh vien Bgch Mai)
Tom tdt:Ung thu phoi la mpt trong nhung ung thu thudng gap va ty le tir vong cao. PET/CT la \iy thuat chan doan hien dai, co vai tro quan trpng Uong quan ly ung thu phoi. Chi djnh ciia FDG PET/CT trong ung thu phdi khong phai t l bao nho la: chan doan u nguyen phat, phat hien di can, xac dinh giai doan, chan doan tai phat, theo doi dap iing dieu trj va lap ke hoach x^trj.
Muc tieu de tai: 1. Xac dinh ty 1? phii hgp giiJa PET/CT (+) vol kit qua giai phdu b$nh; 2.
Xac dinh ty le di can va moi lien quan giiia miic dp hap thu FDG vdi kich thudc, vj tri tdn thuong d b?nh nhan ung thu phoi khong t l bao nho.
Doi tiTffng nghien ciiu : 82 b?nh nhdn co chan doan u phdi, chup PET/CT t^i Trung tam Y hpc hat nhan va Ung budu B|nh vi$n Bgch Mai, co giai phau benh doi chieu.
Phmmg phap nghiSn cuu; hoi cuu va tien ciiu.
Ket qua: 1. Ty 1? phii hpp giua PET/CT (+) vdi giai phau benh ung thu phdi khdng tl bao nho la 94,7%; dp nhay cao: 94,7%. 2. Chup PET/CT toan than giup phat hien dugc tat ca cac tdn thucmg di can, trong do bgch trung that (60%), hach thugng don (20%) xuong (26,7%), nao (18,7%), di can phoi, gan, tuyen thugng th|n vdi ty ie thdp han. 3. Tdn thuong u nguyen phat va cac ton thuofng di can deu co dp hap thu FDG cao, gia tri SUV trung binh cua u nguyen phat la 7,91; cua cac tdn thuong di can bach trung that la 5,96; di can nao la 13,72, di can xuong la 9,21. 4. Cd mdi tuong quan ty le thuan giiia kich thudc tdn thuang va miic dp hap thu FDG (qua gia tri SUV) vdi p<0,05. Tdn thuang cd kich thudc cang Idn thi miic dp hap thu FDG cang cao: nhdm u nguyen phat SUV trung binh ciia nhdm kich thudc l-2cm la 4,35; nhom >2-4cm la 6,53 va nhom >4cm-8cm la 10,27; nhom hach di can SUV trung binh cua nhom kich thuoc 0,5-lcm la 4,75; nhdm >l-2cm la 5,72; nhom >2-3cm la 7,84; nhom
>3cm la 7,92; tdn thuang di c3n phdi SUV trung binh cua nhdm kich thudc <lcm la 1,78;
nhom >l-2cm la 4,35. 5. Chyp PET/CT lam thay ddi giai doan bpnh d 32% b?nb nhan, giup xac dinh phuang thirc dieu tri dieu trj dung.
Kef luan: Chup PET/CT rkt cd gid trj trong chan doan ung thu phdi khdng te bao nho.
I. DAT VAN DE:
Ung thu phoi Id mdt trong nhihig loai ung thu thudng gap nhat va la nguyen nhdn gay tu vong hdng ddu trong cdc loai ung thu. 6 Viet Nam day Id loai ung thu hay gap nhdt d nam gidi va diing hdng thii nam d nH gidi. Ung thu phdi co tien lugng xau, ty le sdng them sau 5 ndm khodng 15%. Hien nay y hge da cd nhieu tien bg trong chdn dodn va dieu tri ung thu phdi nhdm cdi thien ket qud dieu tri. Ky thu$t chup PET/CT (chup cdt ldp bdng biie xa positron kit hgp vdi chup eat ldp vi tinh) ra ddi dem l^i nhilu Igi icb trong chan dodn ung thu ddc biet Id ung thu phdi, lymi)homa, ung thu vii va ung thu ddu mat ed. Doi vdi ung thu phdi khdng phdi te bdo nhd tren the gidi da cd nhilu nghien ciiu chiing minh Igi ich cua PET/CT trong chdn dodn cung nhu theo doi dieu tri. Tai Trung tam Y hgc hat nhdn va Ung budu Benh vien Bach Mai, tir thdng 8 ndm 2009 tdi nay da tiln hdnh chup PET/CT cho han 1200 benh nhan, chu y6u id benh nhan ung budu. Trong do cd 250 benh iihan (21% tong sd benh nhan) dugc chan doan la U phdi (chiem ty le Idn nhdt trong cae loai benh ung budu: 21% tdng sd b^nh nhan).
Chi dinh cua FDG PET/CT trong ung thu phdi la chdn doan tmg thu nguyen phat, chdn doan di cdn, xac dinh giai doan bfnh, du bdo ddp iing vd ddnh gid hieu qua dilu trj, lap kl hoach xa
480 Hdi nghi Khoa hoc vd Cdng nghe hgt nhdn todn qudc idn thir IX, Ninh Thugn 18-19/8/201}
tri, theo ddi phdt hien tai phdt. Ky thudt chup PET/CT la ky thudt hifn d^, mdi cd t£ii Vi^t Nam chua Idu nen eon rdt it nghien ciiu ve gid tri cua PET/CT trong chan dodn benh ung thu noi chung vd benh ung thu phdi khdng te bao nhd ndi rieng.
Nghien ciru ndy dugc tiln hanh vdi muc tidu: xdc dinh ty I? phu hgp giira hinh anh PET/CT (+) vdi kit qud gidi phdu binh chdn dodn ung thu phdi khdng te bdo nhd; xdc dinh ty li di cdn vd mdi liin qua giira muc do hdp thu FDG vdi kich thudc, vi tri tdn thuong a b^nh nhdn ung thu phdi khong te bdo nhd.
II. DOI TLTONG VA PHU'ONG PHAP NGHIEN ClTU:
1. Doi tuong nghien cihi
82 benh nhdn cd chdn doan U phdi, dugc chup PET/CT tai Trung tdm Y hgc hat nhdn vd Ung budu vd dugc lam gidi phdu bdnh de ddi chieu md bSnh hgc.
2. Phutrag phap nghien cuu
- Phuong phap nghien cim: hdi ciiu vd tien cdu.
- Thdi gian nghien ciiu: tir thang 04/20101 din thdng 04/2011.
- Phdn tich cdc kit qua chup PET/CT vdi F-18 FDG dua vdo: so lugng, vi tri, kich thudc tdn thuang, gid tri hdp thu FDG chudn: SUV (standard uptake value).
SUV=[mCi/ml (su phan ra da hieu chinh) cua td chiic m6]/[lilu tidm (mCi)/gram can ndng]
Gid tri SUV cua tdn thuang tim thdy dugc so sdnh vdi hoat do phdng xa be mdu trong trung thdt (SUV trung bmh bl mau=2,5). Vdi cdc gia tri SUV tir 2-2,5 thi nghi ngd giiia t6n thuang Idnh tinh vd dc tinh. Vdi cac gid tri SUV > boat do phdng xa be mdu trong trung thSt (2,5) CO thi xdc dinh tdn thuang dc tinh.
- So sanh vdi ket qud gidi phau benh.
- Phuong phdp xd ly sd lieu: Phdn mem SPSS 15.0.
III. KET QUA NGHIEN CUXJ:
Bdng 1. Ddc diem binh nhdn Gioi
Nam Nil Nam + nfl:
n 62 20 82
Ty le (%) 75,6 24,4 100
Tuoi thap nhat 33 28 28
Tuoi cao nhat 86 75 86
Tudi tmnB binh 58,77±10,45 55,68±12,10 58.02
Nhan xet: Ty le nam bi benh nhi^u hon nQ, ty le la 3,2:1. Do tu6i trung binh hay gap la 58 Bdng 2: Kit qud ddi chiiu suphii hgp giia PET/CT vdi gidi phdu b$nh:
Chi tieu PET/CT (+) PET/CT (-) Tong
GPB (+) 71 4 75
GPB (-) 3 4 7
Tong 74 8 82 Ghi chii: PET/CT (+): hinh anh PET/CT huomg tcri chin doan la ung thu ph6i.
PET/CT (-) : Hinh anh PET/CT khong chin doan la ung thu ph6i.
GPB (+) : giai phlu benh la ung thu ph6i khong tt bao nho.
GPB (-) : Giai phau benh la t6n thuang lanh tinh.
Hgi nghi Khgg hgc vd Cdng nghe hgt nhdn todn quic lin thu IX, Ninh Thudn I8-19/8/20II 481 Nhan xet:
- Ty 1? phi hcjrp giua PET/CT (+) va giai phlu benh la ung thu phSi khong ti bao nho la 94,7%.
- Do nhay ciia PET/CT trong nghien ciiu nay la 94,7%.
- Ty le duong tinh gia la 3,6%. Ty le am tinh gia la 4,8%.
-Do chinh xac la 91,2%.
- Dp dac hieu con rat thap (57,1%).
Bdng 3: Tin thuang di cdnphdn Iggi theo vi tri (n=75) Vi tri di
can n Tj' 1$ %
Hach trung that
45 60,0
Hach thuong
don 35 46,7
Ph5i 10 13,3
Mang phoi
7 9,3
Hach 6 bung
7 9,3
Di can nao
14 18,7
Xtiong
20 26,7
Gan 5 6,7
Tuyen thucmg than
5 6,7 Nhan x6t: T^ Id di can nhieu nhdt Id vdo bach tnmg that (hach rdn phdi va hach trung that Cling ben): 60,0%, tilp theo la di can vao bach thugng don: 46,7%) (trong do 92% Id di can hach thugng ddn cimg ben vdi u nguyan phdt), xuong: 26,7% (trong dd vi tri di can nhieu nhdt
vdo xuong Id than cde ddt sdng, tilp theo la cdc xuong sudn); di can vao nao: 18,7%; di can phdi la 13,3%, di cdn vdo mang phdi, hach d bung, gan va tuyen thugng than vdi ty le it hon.
Bdng 4: Gid tri SUV theo vi tri tdn thuang
\ y i tri ton Xthuong SUV \
n
SUV trung b i n h i S D SUV Min SUV Max
U nguyen
phat 75 7,91±4,40
0,99 27,11
Di can phoi
10 3,29±0,86
0,91 5,96
D i c a n hach trung t h i t
45 5,96±2,63
1,74 13,S1
Di can h^ich t h u g n g
don 35 5,83±3,11
1,33 13,97
D i c a n nao
14 • I3,72±6,14
7,45 19,73
Di can x u o n g
20 9,21±7,33
3,79 34,75
Di can gan
5 6,36±2,20
3,66 8,41
Di can tuyen thu(?ng
than 6 11,08±4,14
6,98 15,69
N h ^ xet: Tdn thuang u nguyen phdt cd do hdp thu FDG cao, gid tri SUV trung binh Id 7,91; cdc tdn thuong di cdn (trd tdn thuong di can phdi) cimg deu cd do hap thu FDG cao.
Bdng 5: Gid tri SUV theo kich thudc ton thuong Duong kinh u
n SUV trung binh
l-2cm 10 4,35
>2-4cm 31 6,53
4-8cm 34 10,27
p=0,002 (Anova test) - Nhom hach di cdn:
Duong kinh hach di cSn n SUV trung binh
0,5-1 cm 8 4,75
>l-2 cm 48 5,72
>2-3 cm 22 7,84
>3cm 9 7,92
p=0,001 (Anova test) - Nhdra ton thuong di can ph6i:
Duong kinh t6n thuang di cSn ph6i n
SUV trung binh
0,4-1cm 25 1,78
>l-2cm 32 4,35
p=0,001 (Anova test)
482 Hdi nghi Khoa hgc vd Cdng nghi hgt nhdn todn qudc lan thir IX, Ninh Thudn 18-19/8/20} 1 Nhan xet: Cd tuong quan ty le thuan gida kich thudc tdn thuong vd gid tri SUV (trone cd ba nhdm tdn thuong vdi p<0,05)
PET/CT phat hien dugc u vdi dudng kinh nhd nhdt la 1,0cm; ciia h^ch Id 0,5cm' va tdn thuang di can phdi la 0,4cm, tuy nhien Id cdc tdn thuong di can phdi cd dudng kinh <lcm thi do hdp thu FDG thap.
Bdng 6: Phdn logi giai dogn binh cua binh nhdn Kphdi truac chup PET/CT (n=75) Trude khi chup PET/CT, phdn loai giai doan theo kham lam sdng vd cdc kit qua xet nghiem (CT, MRI, xa hinh xuong,...) ma benh nhan cd.
Giai doan n Ty le %
I 5 6,7
11 16 21,3
III 23 30,7
IV 31 41,3
T6ng s6 75 100 Nhdn xet: Nhdm cdc benh nhan giai doan I cd ty le 6,7%; giai doan II: 21,3%;
111:30,7%; iV: 41,3%.
Bdng 7: Phdn logi giai dogn benh cua benh nhdn Kphdi sau chi^p PET/CT (n=75) Giai doan
n Ty le %
I 3 4,0
II 5 6,7
III 20 26,7
IV 47 62,6
T6ng so 75 100 Nhan xet: da so cac benh nhan a giai doan muon, nh6m cac benh nhan giai do^ 111 v^
IV chiem tren 80%. Sau khi chup PET/CT da nang giai doan Clia 2 b|nh nhSn giai doan I len giai doan IV, 8 benh nhan giai doan II len giai doan III va 3 benh nhan giai doan II len giai doan IV, 11 benh nhan giai doan III len giai doan IV vi phat hien them cac t6n thuong di can xa. Khflng mot benh nhan nao giam giai doan duoc phat hien trong nghien ciiu niy. T6ng s^
benh nhan xac dinh thay doi giai doan la 24/75=32 % benh nhan.
IV. BAN LUAN
1. Dac diem benh nhan: Cac benh nhan ung thu phdi chu ylu la nam gioi, tSn suSt hay gap nhat 6 do tuoi 55-65 tuoi. Ket qua nhien cuu nay cua chiing t6i ciing phu hpp vol nhieu nghien ciiu khac.
2. PET/CT CO gia tri Ion trong phat Men u nguyen phat va hach di cSn. PET/CT co dp nhay, do dac hieu va do chinh xac cao hon CT va MRI don thuin. Trong danh gia ban dau tren 82 benh nhan, chiing toi xac dinh dugc do nhay la 94,7%, theo mot s6 nghien cuu cua cac tac gia nuoc ngoai la 93-95% [6,9], dp chinh xac la 91,2%. Dp dSc hi$u con thjp vi hai nguyen do: co mau con nho, cac benh nhan co giai phau benh thong qua viec noi soi sinh thiSt, choc sinh thilt xuyen thanh, chi co mpt s6 it benh lihan dupe phau thuat sau chyp PET/CT. Vice choc sinh thilt xuyen thanh hoac npi soi sinh thilt nhilu lin nlu chua dung vj tri CO ton thucmg ac tinh se cho kit qua giai phau benh am tinh. Chiing toi se tiep tuc nghiSn ciiu dl danh gia cac gia tri nay ddng thoi khuyin cao nen chup PET/CT truoc khi tiln hanh sinh thiet u, PET/CT se chi diem cho vi tri sinh thilt cho kha nang giai phau b$nh duong tinh cao. Ty le phu hpp giua PET/CT (-I-) va giai phiu bSnh ung thu ph6i khong tl bio nh6 la 94,7%, ty le rit cao. Ty le duong tinh gia cua PET/CT la 3,6%. PET/CT thutog cho kit qua am tinh gia doi voi ung thu phoi dang ung thu bilu mo tilu phi quan phi nang, ung thu bieu mo tuyin chi nhiy do chiing co mile dp hip thu FDG thip [10] hojc ton thuang u kich thudc con nho (duoi 2cm).
Hdi nghi Khoa hoc vd Cdng ngh? hgt nhdn todn qudc Idn thu IX, Ninh Thugn 18-19/8/2011 483 3. Ung thu phdi cd the di can tai phdi, di can bach hoac di can xa. Kit qua nghien ciiu cho thdy PET/CT cd thi giup phdt hien hdu hit cae tdn thuong di can. Ung thu phdi chu ylu di cdn vao h?ch trung thdt (50%) benh nhan cd di cdn bach trung thdt); cac vi tri di can thudng gdp tilp theo Id bach thugng ddn, xuong, nao, di can phdi vdi ty le Idn lugt Id 46,7%, 26,7%, 18,7% vd 13,3%. bd nhay cua PET/CT trong phat hien bach di cdn theo Rankin ndm 2000 la 95-99%. PET/CT ciing rdt nh£ty trong phat hien di cdn xuong, theo bao cdo cua Songa vd cpng sir nam 2009 do nhay cua PET/CT Id 94,3% so vdi 74%i ciia xa hmh xuong bdng mdy.
SPECT vdi Tc-99m-MDP [12].
4. Trong xdc dinh giai doan benh, chup PET/CT ldm thay ddi giai doan ciia 32% benh nhdn tir giai doan I, II vd III thdnh giai doan IV, tir dd giiip ldm thay ddi phac dd dilu tri ciing nhu tien lugng bdnh. Theo cdc nghidn ciiu khac thi PET/CT cd kha nang phat hien, thay ddi giai doan benh tir 39-67%) [8,11]. Ddi vdi cdc benh nhan ung thu phdi, khuyin cao nen chup PET/CT danh gid giai doan trude khi dieu tri de xac dinh giai doan benh chinh xac, tu dd cd phac dd dieu tri phii hgp, hieu qud cung nhu biet dugc tien lugng benh.
5. Miic do hdp thu FDG duge danh gid qua gid tri SUV. Cd mdi tuong quan ty le thudn cd y nghia giiia dudng kinh tdn thuang vd gid tri SUV. Dudng kinh tdn thuong cang Idn thi miic do hdp thu FDG cdng cao. Bdo cao ciia Dang Yaping tai hdi thdo FNCA Cyclotron 2010 cimg cho ket qud tuang tu. Ddi vdi nhung tdn thuong di cdn phdi dudng kinh
<lcm, thi mdc do hap thu FDG thdp, vi vay phai chii trgng den CT de khdng bd sdt tdn thuang. Ngodi ra trong mdt so nghien ciiu cua nude ngodi cho thdy SUV cdn cd gid tri du bdo ddp ling dieu tri vd tien lugng benh. Neu gia tri SUV ciia u nguyen phdt hoac hach vimg di cdn cang cao thi thdi gian sdng them se cdng gidm xudng [5,7]. Chiing tdi se tien hdnh theo ddi cac benh nhan ndy vd sdm cd ket ludn ve mdi lien quan giiia gid tri SUV va ddp ung dieu tri, thdi gian sdng them.
6. Nhd xdc dinh chinh xdc cdc khdi u, bach di cdn, PET/CT giiip viec ve ranh gidi cdc tdn thuang trong lap ke hoach xa trj chinh xdc hon CT don thuan, t
MOT SO C A LAM S A N G M I N H HOA:
Ca ldm sdng I: Benh nhan nil, 53 tudi, chdn dodn: Ung thu phdi (giai phdu benh: ung thu bieu md tuyen), chup PET/CT de xdc dinh giai doan benh trude dilu tri:
Hinh 1: Khoi u dc tinh phdi phdi di cdn hgch, di cdn tuyin thuomg than phdi (mUi ten).
Ca lam sang 2: Benh nhan nam, 49 tudi, chdn doan: Ung thu di can nao ehua ro nguyen phdt, chyp PET/CT dl tim tdn thuong nguydn phdt.
484 Hdi nghi Khoa hoc vd Cdng ngh? hgt nhdn todn qudc idn thu IX, Ninh Thudn 18-19/8/201}
-Cii
Hinh 2: khoi u dc tinh phdi phdi di cdn hgch, di cdn ndo (mUi tin). Gidi phdu b?nh sau chiiip PET/CT Id ung thu biiu md tuyin.
Ngodi gid tri cua PET/CT trong chan dodn, xdc dinh giai d o ^ ung thu ph6i khdng te bdo nhd, PET/CT cdn cd chi dinh danh gid dap iing dieu tri, theo ddi phdt hien tai phat va l§p ke hoach xa tri.
Ca lam sdng 3: benh nhdn nam, 60 tudi, chdn doan ung thu ph6i T2N0M0, sau dieu trj hda chdt 3 dot, khdi u ddp iing mdt phdn, nhd ban vd gidm hap thu FDG, sau xg trj vi h6a chat 3 dgt tiep, u tan het.
Khdi u phdi trude dieu Ui:
max SUV=7,2
/ ' ^ ' \
Khdi u phdi sau dieu tri iioa chdt 3 dgt: max SUV=3,5
Sau xa tri vd hda chat 3 dgt tiep: u tan bet Hinh 3. Hinh PET/CT a mat phdng cdt ngang thdy khdi u sau truac diiu trf (mui ten lien)
vd nhd.hdn sau dieu tri hda chdt 3 dot (mUi ten dirt)
Trong sd cac benh nhan thudc nhdm ddi tugng nghien ciiu, cd 6 b^nh nhan dugc l?p kd hoach md phdng xa tri tren hinh dnh PET/CT. PET/CT giiip xae djnh the tich khdi u sinh hge: BTV (biological tumor volume) Id the tieh khdi u d miic do chuyin hda, sdm va chinh xac hon the tich khdi u thd: GTV (gross tumor volume) ma chiing ta nhin thdy tren CT hodc MRI. Tu dd viec lap ke hoach xa tri chinh xae hon va mang lai bidu qua cao hon trong dieu trj. Huih 4: Trudng hgp mgt benh nhan chup PET/CT md phdng I$p kl hogch xg tri gia tdc.
Ca ldm sdng 4: benh nhan nam, 52 tudi, chdn doan: U phdi/ X?p phdi.
Hinh 4. Tren CT thdng thudng khong phdn biet duac ro rdng td chuc u, vitng x?p phdi. Triri hinh PET/CT giiip phdn biet ro td chuc u (viing sdng mdu), viing x?p phdi (mUi ten dut nit) vd vung hoai tir (mUi ten liin), chi diim cho viec sinh thiit u ldm gidi phdu b^nh cUng rihu xdc dfnh the tich dich trong lap ki hogch xg tri.
Hgi nghi Khog hgc vd Cdng nghe hgt nhdn todn qudc lan thi IX, Ninh Thugn 18-19/8/2011 485 V. KET LUAN:
Kit qua nghiSn ciiu it 82 benh nhan ung phoi dupe chup PET/CT cho thiy:
1. Ty IS phO hpp giOa PET/CT (-^) vdi giai phau bSnh ung thu phii khong tl bao nho 14 94,7%; ty 1? duong tinh gia la 3,6%; dp nhay cao (94,7%).
2. Chup PET/CT toan than giiip phat hien dupe tit ca cac tin thupng di can, nhilu nhit vao hach ttung thit (60%>), hach thupng don (20%) xuong (26,7%), nao (18,7%), di can phii, gan, tuyin thupng than vol ty le thap hon.
3. Tfln thuong u nguyen phat va cac t6n thuong di can deu co dp hip thu FDG cao, gia tri SUV mmg binh cua u nguyen phat la 7,91; cua cac ton thuong di cSn hjich trung thit la 5,96; di can nao la 13,72, di can xuong la 9,21.
4. Co moi tuong quan ty 1? thuan giGa kich thuac ton thuong va miic dp hip thu FDG (qua gia tri SUV) vol p<0,05. Ton thuong co kich thuoc cang Ion thi miic dp hip thu FDG cang cao: nhom u nguyen phat SUV tnmg binh cua nh6m kich thupc l-2cm la 4,35; nhom 2- 4cm 14 6,53 va nhom >4cm-8cm la 10,27; nhom hach di can SUV trung binh ciia nhom kich thu6c 0,5-lcm la 4,75; nhom l-2cm la 5,72; nhom 2-3cm la 7,84; nhom >3cm la 7,92; nhom ton thuang di can phoi SUV trung binh cua nhom kich thuac <lcm la 1,78; nhom >l-2cm la 4,35.
5. PET/CT lam thay doi giai doan benh a 32% benh nhan, giiip chuyin huong dilu tri diing va tien lupng benh dupe chinh xac.
Vol kit qua nghien ciiu tren cho thiy PET/CT rat co gia tri trong chin doan s6m, phat hi$n di can, tai phat, xac dinh giai doan va lap kl hoach x^ tri cho b|nh nhan ung thu phii khdng te bao nho.
VI. TAI LIEU THAM KHAO
[1] Phan Sy An (2009): Bai giang Y hpc hat nhan, NXB Y hpc Ha Npi, Y hpc hat nhin chin doan, tr. 55-75.
[2] Nguyen Ba Due, Chin doan va dieu tri ung thu, Ung thu phi quan phii, NXB Y hpc Ha Npi, nam 2007, tr. 75-79.
[3] Mai Trpng Khoa (2009): LTng dung ky thuat PET va PET/CT trong lam sang. Tap chi Y hpc lam s4ng, 5/2009, tr. 19-25.
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