JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
Dac dilm lam sang, can lam sang & benh nhan ung 1 ph6i khong tg bao nho dirffc dilu tri bang phSu thuat soi long nguc
CUnical and paraclinical characteristics of non - small cell lung cai patients whom were treated by video-assisted thoracoscopic surgery
Vu Anh Hii*, *Benh vien Qudn, Mai Van Vign**, **Benh vien Trung uang Qudn dc
Pham Vinh Quang'" ***HocviSnQi
Muc tiiu: N h i n xet d i e diem lam sang, can lam sang d bdnh n h i n ung thU phoi khdng t d bao nhi duoc dIeu trj bang phau t h u i t ndi soi Idng ngUc. Doi tuang vd phuang phdp: Nghien cdu tien cdu trdn 9' benh n h i n ung thU phdi khdng te bao nhd duoc didu trj b i n g p h i u thuat ndi soi Idng ngiic cat thCi;
phdi v i vdt hach tai Benh vidn Pham Ngoc Thach, thdi gian t d 11 /2011 ddn 07/2014. Kit qud: Tudi truni binh; 55,5 ± 10,8; t J le nam/nd: 1/1; diem Karnofsky t U 70 den 90; trieu chdng lam sang t h u d n g gap gdm: Dau nguc (58,9%), ho khan (43,6%), ho ra mau (20,2%). Ket q u i chup phim cat Idp v i tinh Idn(
nguc: 100,0% cd tdn thuong dang u vi t r i ngoai vi, kich thUdc u t r u n g binh 3,1 ± 1,0cm (nhd nhat 1cm Idn nhat 5cm), hach NI t ^ le 4,3%. Phuong phap chan d o i n te bao, m d benh hpc trudc p h i u t h u i t gdm Sinh thidt xuyen thanh nguc hudng dan c i t Idp vl tinh chl^m 46,8%, xuyen thanh phd q u i n 12,8% vi phau thuat ndi soi ldng ngUc 40,4%. Ung thU phdi t i p bidu m d tuyen chiem chd yeu (94,7%). Kit ludn Phau t h u i t ndi soi Idng nguc duoc chi cRnh d nhOlig benh nhan cd kich thudc u nhd dudi 5cm, vj tr ngoai vi v i hach trung t h i t {N2) am tinh.
TUkhda: Ung thU phdi, u phoi ngoai vl, p h i u thuat ndi soi Idng ngUc cat thdy phoi.
Summary
Objective: Reviews clinical and paraclinical charaaeristics in non - small cell lung cancer patient who were treated by Video-Assisted Thoracoscopic Surgery (VATS). Sudyect and method: Prospectivi study on 94 non - small cell lung cancer patients w h o have been lobectomy by VATS at Pham Ngoi Thach Hospital from November 2011 t o July 2014. Result: The mean of age was 55.5 ± 10.8; thi proportion of male/female was 1/1; common clinical symptoms are chest pain (58.9%), dry cougl (43.6%) and hemoptysis (20.2%). The lesions on computed tomography film included: 100 0% periphera lung tumors with the average of size was 3.1 ± 1 .Ocm (smallest in 1 cm, largest in 5cm), N I lymph nodi posrtive was 4 3 % . Cell type consists: Adenocarcinoma 94.7%, squamous carcinoma 4.2% and large eel 1.1%. Condus/on: Video-Assisted Thoracoscopic Surgery lobectomy was indicated for patients with thi size of lung tumors less than 5cm, peripheral location and mediastinal lymph node (N2) was negative.
Keywords: Lung cancer, peripheral lung tumor, Video-Assisted Thoracoscopic Surgery lobectomy.
Ngaynhan bdi: 17/11/2016, ngdy chdp nhdn idng: 20/1/2017
Nguaiphan hdi: Ma, Van Vien, Email- [email protected] - Bfnh vien Trung uang Qudn doi 108
TAP CHl Y DLTOC LAM SANG 108 rap 12-56 1/2017
I.Datvande
P h l u t h u a t n6i soi l o n g ngtfc (PTNSLN) cat thDy phoi d i l u trj ung t h U p h o i khdng t e bao n h o (UTPKTBN) lan dau t i e n duae thirc hien bdi Rovario G nam 1991. Nhffng nam gan day, p h i i d n g phap phau thuat nay ngay cang duac Ung d u n g rdng rai. La phuong phap phau t h u a t dugc khSng ^ n h co n h i l u UU diem so vdi phau thuat m d nguc truyen t h d n g nhu giam dau, giam t J le bien chiftig sau m o , rOt ngSn t h d i gian nSm vien...Tuy vay, PTNSLN ed ehi dinh han che so vc^ m o m d , ehu yeu d nhutig benh nhan UTPKTBN giai doan sdm [8], [10].
ChOng toi t h i i c hien nghien ciifu nham Whan xit mot sd ddc diem ldm sdng vd can ldm sdng d nhu^g b^nh nhdn dugc chi djnh dieu tn bdng phuang phdp phau thudt ndy.
2.D6i tiftfng va phi/cmg phap 2.1.Doituong
Gom 94 b&nh nhan UTPKTBN dugc dieu trj ngoai khoa bSng PTNSLN tai Benh vien Pham Ngoc Thach - thanh pho Ho Chf M i n h , t h d i gian tii thang 11/2011 den 7/2014.
Tieu chuan chgn benh; La nhiJng benh nhan UTPKTBN (theo ket qua sinh t h i e t chan doan trtfde phau thuat va m d benh hoc sau p h l u thuSt) dugc phau thuat eat thCiy, vet hach dieu trj bang PTNSLN.
Ti^u chuan loai trii: Binh nhan dugc PTNSLN dieu trj nhung ed k^t quS m o benh sau phau t h u a t khong phai UTPKTBN.
2.2. Phuang phdp
Nghien eUu m d th, tien ciJu va theo ddi dpc.
3. Ket qud
3.1. Oac 3iim chung
2.2.1. Cdc chi tieu nghiin ciJi/
Nghien edU dae diem lam sang: Tudi, gidi, tinh trang toan than theo thang dilm Kanoftky.
Tri§u ehufng co nang; Dau ngUc, ho khan, ho ddm, met mdi.
Trieu chiifng thiie the: Ho ra mau, khd thd, ri rao phe nang giam cue bd, sOt can (gl3m a 5% trong iLfpngcothl).
Dae dilm ton thuong tren phim cat \dp vi tinh (CLVT) long ngiie: Chup CLVT long ngiie duoc thiic hien cho tat c^ benh nhan trUdc phau thuat bang may Phillip Brltliance 16 Idp elt, vdi hinh anh ehup ed va khdng cln quang. Djnh nghTa u phoi theo Ost D va CS. (2008) [9]: La khoi md tren phim tren phim CLVT long ngiie.
Vj tri u trung tam hay ngoai vi theo phan loai eCia Shields T.W (2009) [11]: U phoi ngoai vi la khdi dUcfc bao xung quanh bdi nhu md phoi; u trung tam la u vung rdn phdi
Kich thiidc u: La sd do theo dudng kfnh Id^
nhat, tfnh bSngcm.
Dac ^ I m tdn thucfng xae djnh qua ndi soi p h i qu^n: Benh nhan duac soi phe quan kiem tra trUde md.
SCf dung may soi Olympus BF - 1T150 vdi dng soi dudng kfnh 5mm. Ghi nhan cac tdn thuong, gdm: PhCi ne niem mac; chay mau hay mau dong long phe qucin;
djeh due long phe quan; hep ldng phi quin do phu ne;
chen ep ldng phi quan; u ndi phi quSn...
Phan loai tip md benh hoe: Theo hUdng dan cua Td chtJc Y te The gidi nam 2001.
2.2.2. XiJtl;^ so lieu Si!f d u n g phan m e m SPSS 16.0.
Bdng 1 . Phan bo theo tuoi va gidi Tudi
< 3 0 3 0 - 3 9 4 0 - 4 9 5 0 - 5 9 6 0 - 6 9 a 70 Trung binh
Nani(n = 48) n
0
%
0,0
0 1 0,0
12 25,0 14 29,2 15 31,2
7 1 14,6
57,7 ±10,9Niir(n=46) n 1 5 4 24 10 2
2,2
%
10,9
Tdng (n = 94) n 1 5
8,7 1 16
52,221,7 4,3 53,3 ±10,2
38 25 9
1,1
%
5,3 17,0 40,4 26,6 9,6 55,5 ±10,8
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY V 0 L I 2 - N '
Biing 2 . T m h t r a n g t o a n thdn
3.1.2. Trieu chUng ldm sdng Diem Karnofsky
7 0 - 8 0 8 1 - 9 0 Tong
Sd benh nhan 61 33 94
T J I e % 64,9 35,1 100,0
Bdng 3. Trigu ehufng ldm sang TrlSu chdng lam sang
Khdng trieu chdng Bau nguc Ho khan Ho ddm Ho ra m i u K h d t h d
Rl r i o phd nang g i i m cue bd H/ISt mdi
Sdtcan
Sd benh nhan (n = 94) 14 56 41 20 19 3 21 15 6
T ; i e % 14,9 59,8 43,6
21,3 1
1 20,2
3,1 22,3 16,0 6,4 3.1.3. Trieu chUng can ldm sdng
Dae diem t d n t h u o n g tr§n phim cit Idp vi tfnh Idng ngiic:
Bdng 4 . Vj trf u phoi V j t r i u
The khu tru
Phdi p h i i
Phdi trai
Ngoai vi Trung t i m Thuy trdn ThUy gida Thuy dudl
Tong Thuy tren Thuy dudi
Tong
Sd benh nhan (n = 94) 94
0 29 15 20 64 20 10 30
T J I e % 100,0 0,0 30,8 16,0 21,3 68,7 21,3 10,6 37,9
TAP CHl Y DUOC L A M SANG 108 Tapl2-So 1/2017
Bang 5. Dac diem u va hach t r e n phim chup cat Idrp vi t i n h long ngUc Dac di^m u va hach
Kich thudc u
Hlnh dang u
Dac diem ben n g o i i u
Bac diem ben trong u
Hach
^ 2 c m
> 2 - 3cm
> 3 - 5cm Trung binh Trdn Oval Nhieu canh Khd x i e djnh Bdrd Cd mui, da cung Cdtua Thuan nhat Khdng ddng ddu Cd hang Vdi hda Phd q u i n khi NI N2
Sd bdnh n h i n (n = 94) 23 30 41
3,1 ± 1 , 0 (Idn nhat 5cm, nhd 31
50 12 1 16 57 42 73 3 13 1 4 4 0
T J I d % 24,5 31,9 43,6 n h i t 1cm)
33,0 J
53,2 M
-•' 1
.' 1
17,0 " ^ 60,6 44,7 77,7 3,2 13,8 1,1 4,2 4,3 0,0
1
K i t qua ndi soi phe quSn:
Bdng 6. K^t qud ndi sol phe qudn K^t q u i ndi soi phe quan
Binh thudng Phu ne nidm mac
Chay mau/ mau dong Idng phe q u i n Djeh ducldngphequan Hep Idng phd quan do phiJ ne Chen ^p Idng phe q u i n
Tong
Sd benh nhan 86
3 1 2 1 1 94
T y l e % 91,5
3,2 1,1 2,1 1,1 1,1 700,0 Phuong p h i p sinh thidt chan d o i n te bao, m d bdnh:
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N'
BSng 7. PhUtfng p h a p sinh thiet chan d o a n Phitfong phap chan doan md bdnh hoc
Sinh thiet xuyen t h i n h phd quan Sinh thiet xuyen t h i n h nguc hUdng dan CLVT PTNSLN sinh thiet
TSng
Sd bdnh nhan 12 44 38 94
T J I e ? i 12,8 46,8 40,4 700,0 BSng 8 . Tip t e bcio hoc
Tip md benh hoc Bleu md tuyen
Te b i o vay Te bao Idn
TSng
S6 bdnh nhan 89 04 01 94
T J I e % 94,7
4,2 1,1 100,0
4.1. Ve ddc diem chung
Tudi trung binh benh nhin trong nghidn cdu I i 55,5 ± 10,8, tap trung ft dp tudi td 40 den 69, chiem ty le 84,0%, nhdm tuoi cd tJ le mac UTPKTBN cao nhit tu 50 - 59 tudi (40,0%). Tudi trung binh va phan bd benh nhan theo nhdm tudi trong nghien cdu tuong tu bao cao cda Bill Chi Viet (2011) d benh nhan UTPKTBN duoc dieu tri bang md md, vdi tudi trung binh Ii 56,8 ± 10,8, do tudi td 40 den 69 tudi chiem ehu yeu (80,8%), nhdm tudi td 50 ddn 59 chiem t^ le cao nhat (27,9%) [61.
Cic bao cio cho thay, benh nhan nam UTPKTBN duoc md mft chiem t / le cao hon nd gidi, tJ le nam/ndtd1,8/l den 9/113], [6]. Chung tdi thay cd sU khac biet ve tJ le nay dbenh nhan duoc dieu trj bang PTNSLN, nd gidi tuong duong nam gidi (tJ le nam/nd I i 1/1). Ket qui tuong tu Scott W.J v i CS.
(2010), ty le nam/nd la 0,4/1,
Theo khuyen nghi Hdi phau thuat Idng ngUc Anh (BTS), nhdng benh nhan cd diem Kamofeky dudi 70 thudc nhdm cd nguy co phau thuat cao [7]. Cic tic gii Cu Xuin Thanh (2002), Nguyen Khac Kiem (2016), md md cat thuy phdi d benh nhan UTPKTBN cd diem Kamofsky > 80 [4]. Trong nghien cdu, chung tdi thuc hidn PTNSLN dieu tri tren nhdng benh nhan cd diem
Karnofsky td 70 trd len, thap hon cic tic gii treni phd hop vdi khuyen nghj cda BTS. I
4.2. Vt trieu chdrng ldm sdng
Boan Thj PhUOng Lan (2014), nghien cdl nhdm benh nhin ung thu phdi cd kich thudc nhat den 7cm, t i c gii cho biet: Sau nguc 49,3%, ho 40,6%, ho ra mau 24,6%, khd,thd nudt nghen 3,0% [1]. Ve die diem lim sing ngoai vi, t i c gii Nguyen Thj Thoa (2005) cho Bau nguc chldm 81,6%, go due cue bd 60,8%, phe nang giim cue bd 51,0%, khd thd 30,6% [5]
Nhu vijj, nhln chung cic trieu chdng lim thudng gap trong UTP I i : Ho khan, dau nguc hi ra mau.
Cic trieu chdng biiu hidn tlnh trang chen s chd cda khdi u nhU: Hdi chdng tmh mach chd nudt nghen...chdng tdi khdng gap trong nc cdu. Die dilm niy cd le do chi phdi bdi tieu d lua chon bdnh nhin nghien cdu duoc dieu trj I PTNSLN, I i nhdng benh nhin UTP cd u ngoai vi doan sdm, tinh trang di can khoang ming ph xam lan co quan lin can chua xiy ra.
4.3. Ve triiu chvtng cdn ldm sang
Bac diem tdn thuong tren phim c i t Idp vi
Idng nguc.
\PCHlY DUOC L A M S A N G 108 T a p l 2 - S d l / 2 0 1 7
Ve phan bo va kfch thUde u phoi
K i t qu3 n g h i l n eUu: U phdi ph^i nhieu hcfn phdi
•ai (ty \i 2,1/1), thDy t r l n nhieu chiem t ^ le cao nhat, au dd den thOy dUdi, thCiy glOa. Kfch thiidc u t r u n g linh tren phim CLVT long ngiie la 3,1 ± 1,0em (Idn ihat 5cm). 100% b i n h nhan cd u phdi ngoai v l .
Oac d i l m phan b d u t h e o t h i j y phdi t r o n g ighlen cUu ehung t d i tUdng t i i nghien cijfu eua cae k gi^ tren n h d m benh nhan UTPKTBN dUcfc dieu trj ihauthuat[4],[6].
Hudng dan eua BTS cho thay: Cd t h e tien hanh )hau thuat dieu t n eho nhQng b i n h nhan UTPKTBN :6 kfch thude u Idn hon 7cm (T3), vj trf u t r u n g t a m , 1 xam lan thanh nguc hay d d t sdng ngUc [7]. Nghien :<Su dieu t n UTPKTBN bang phUcJng phap p h l u huat md cOa eac tae gia t r o n g nude nhU Cij Xuan Thanh (2002) [4], BiJi Chi Viet (2011) [6] eho thay:
'hau thuat duoc chi djnh cho nhung b i n h nhan ed (ich thudc u phdi len tdi 10cm, u xam lan t h ^ n h iguc va ed di can hach t r u n g that. N h u vay, vdi phau :huat md ngiie thi kfch thUde u phoi Idn, vi tri u
;trung tSm hay ngoai vi), u xam Icin thanh ngiic
<h6ng phai la nhufng chdng chi ^ n h .
Tuy vay, khi i5lig d u n g PTNSLN d i l u tri UTPKTBN: Kich thUde, vj trf, tfnh chat xSm l^n tai ehd :0a khoi u 1^ nhCtng tieu chuan t r o n g chi d j n h . Theo Scott W.J va CS. (2010) [10]. Begum S va CS. (2014) [8], PTNSLN dupc chi dinh cho nhQng b i n h nhan cd kfch thude u phdi Idn nhat den 5cm, ehua x3m l^n th^nh nguc. Ylm APC va CS. (2002) cho biet: Khoi u kfch thude tren 4cm, x l m lan thanh ngiie, ed di can hach trung that la nhCtng ehdng ehi d m h t r o n g Ung dung PTNSLN d i l u t n UTPKTBN [12].
Nhu vay, k i t qua nghien cho thay: Dae d i l m ve kfch thude (Idn nhat 5cm), vj trf u phdi (ngoai vi), tfnh chat xSm lan (chUa xam l^n thanh ngiic) va di can hach trung that (N2 am tfnh) d nhUng benh nhln dugc ehung tdi ehi djnh dieu tri bang PTNSLN la tuong t i i cac cae tac gia tren.
V I dae diem u phdi
Y van the gidi va trong nUdc eho biet: CQng vdi tuoi, thdi quen hut thudc, kfch thUde u...dae diem i/e bdva ben trong u la nhQng yeu t d cd l i l n quan 3ln bSn chat u phdi. Tac g i ^ Ost D (2008) eho b i l t :
Bd khdi u ac tfnh ed xu h u d n g khdng deu, cd m i i i hoae cd tua gai; khdi u ed tua gai hay vanh tia t h u o c n h d m cd nguy cd ae tfnh cap do eao nhat [91. Theo CQ Xuan Thanh (2002), UTP d benh nhSn t r l n 60 t u d i , hinh einh u ed m u i , da cung c h i l m t;y' I I tQ 23,6% den 30,0%; u ed gai tua, khe nOt, t^ le 23,6%
d i n 29,3%; n o t vdi hda t r o n g u, t y 114,3% d i n 8,5%;
u x l m lan t h a n h ngiie 10,2% [4].
Ket q u i nghien cQu cho thay: U ed m d i , da eung c h i l m chQ y l u (ty' I I 60,6%), t^' le u cd tua la 44,7%.
Vdi hda t r o n g u t y le t h a p (1,1%).
Dac d i l m t d n t h u o n g qua soi phe quan Theo Doan Thj PhUtfng Lan (2014), eae hinh anh bat t h u d n g khi soi phe quan cd t h e gap d b i n h n h l n UTP bao g d m : PhO ne niem mac {t;^ le 11,6%), dich due ldng phe q u i n (10,1%), phu ne chit hep Idng phe quan (7,2%), mang sac t d den t h a n h p h i q u i n (7,2%)...[1].
Ghi n h l n cac t d n thUdng p h l t hien khi soi phe q u i n d nhCfng benh n h l n UTP ducfc dieu trj bSng phau thuat m d , tac g i l Bui Chf Viet (2011) eho biet: U ndi p h i q u i n chiem t y le 30,4%, chen ep tU ngoai vao p h i quan 3,6% [6).
Chung tdi thay, hinh I n h soi phe quan btnh t h u d n g e h i l m ehQ y l u (h/ le 91,5%). Cac t o n thUcfng cd t h e gap, g o m : PhQ n l n i l m mac (3,2%), dich due long phe q u i n (2,1%), c h l y mau hay mau d p n g l o n g p h i quan, hep long phe q u i n do p h u n l (1,1 %). NhU vay, ehung t d i khdng PTNSLN dieu t n cho nhQng benh n h l n ed u npi phe q u i n .
Phuong p h i p chan doan, t i p t l bao m d b e n h hpc trude p h l u thuat.
56 benh nhan dupc ch^n doan te bao hoac m d hpc trude p h l u thuat bang cae ky t h u a t ft xam n h i p (sinh t h i e t xuyen thanh phe q u i n hoae xuyen t h i n h ngiie (XTN) hudng dan CLVTO, 38 benh nhan dupe chan doan diia t h e o k i t q u i xet n g h i e m m d benh hoc tQe thi mau m d dupe sinh thiet bang PTNSLN, t r o n g d d : Benh n h l n da dupc sinh t h i l t xuyen thanh phe q u i n t} le 4 2 , 1 % ; sinh thiet XTN hUdng dan CLVT 34,4%; k i t h p p sinh t h i l t xuyen t h a n h p h i q u i n va XTN hUdng dan CLVT 15,8%; 7,9% khdng thiie hien sinh t h i l t d o u n h d , nam sau t r o n g nhu m d phoi. N h u vay, sinh t h i e t bang PTNSLN dupe ap
123
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N
d u n g t r o n g nghien cQu nay dugc t h i i c hien khi cae ky t h u l t xam n h i p da t i l n h l n h khdng dem lai k i t q u i chan doan.
ChOng tdi thay, t i p bieu m o t u y i n chiem ehCi yeu (ty 1194,7%). UTP te bao vay va t e bao Idn chiem t y l e t h a p ( 4 , 2 % v a 1 , 1 % ) .
Dac d i l m t i p m o benh hpc UTP ngoai vi dUpc d l cap t r o n g eae bao e l o cho thay, t i p bleu m d t u y i n ludn c h i l m Uu t h i . Theo D d Kim Que (2010), t ^ le la 8 0 % [2]; Le Sy S i m (2009), t y le 100% [3].
Bao eao v l tfp m d benh hpc UTP d nhQng b e n h nhan dupc m d m d cd sii khae b i l t nhat d j n h , t i p bieu m d t u y i n t h u d n g ehi e h i l m t^ le dUdI 60%.
"Rieo Cu X u I n Thanh (2002), t J le UTP tfp b i l n m d t u y i n la 29,3% [4].
N g u y i n n h l n eua sii khae biet nay cd le la d o sii khac nhau t r o n g chi d j n h eua m o i p h u o n g phap phau thuat: PTNSLN dupe chi ^ n h t r l n nhQng benh nhan cd u phdi ngoai vi, t r o n g khi m d m d dUpc thUe h i l n ea tren nhQng b i n h n h l n u phdi t r u n g t a m . Chfnh vj trf u phoi la y l u t d ehi phdi dac diem m d b i n h hoc n h u da trinh bay d t r l n .
5. Ket l u a n
Qua nghl&n cUu tren 94 benh nhan UTPKTBN dupc PTNSLN eat thuy, vet h^ch d i l u t n , chung tdi rut ra k i t luan sau:
Trieu chQng lam sang thUdng gap la dau ngiie (59,8%) va ho khan (43,6%).
Hinh anh t o n t h u o n g dang u tren phim CLVT vdi kich thude Idn nhat d i n 5cm, vi trf ngoai vl, u chUa xam l^n thanh ngtie va khdng cd hach t r u n g that.
K i t q u i soi phe q u i n binh thudng c h i l m chQ y l u (tJ le 91,5%), khdng ed trudng hpp u ndi phe quan.
Phuong p h i p chan doan te bao, m d benh hpc trUde phau thuat g o m : Sinh thiet XTN h u d n g dan CLVT e h i l m 46,8%, xuyen thanh phe q u i n 12,8% va PTNSLN 40,4%. UTP bleu m d tuyen la tfp t e bao chiem chO y l u (94,7%).
Tai lieu t h a m k h a o
1. Doan Thi Phuong Lan (2014) Nghien cOu ddcdiim ldm sdng, can ldm sdng vd gid tri <^ua sinh thiit cdt xuyen thanh ngUc dudl hudng dan cua chup cdt Idp vi tinh
trong chdn dodn cdc ton thuang dang U dph I n T i l n sy Y hoc. Dai hpc Y Ha Ndi, H I Ndi.
2. 0 6 Kim Q u i (2010) Ph&u thudt cdt ndt d phoi qua dUdng md ngUc nhd vdi noi sc nguc h6 tra. Y hpc T h i n h p h d Hd Chf Mi (phu b i n sd 2), tr. 41-45.
3. Le Sy S i m (2009) Sinh thiet U phoi ngogi bien dinh giai doan Ung thu phoi nguyen phdt bar\
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