tTNG DVNG KY THUAT CHUP PET/CT TRONG CHAN DOAN VA M O PHONG LAP KE HOACH XA TRI GIA TOC UNG THU*
V O M MUI HQNG
MAI TRONG KHOA, TRAN DINH HA, LE CHINH DAI, T R A N HAI BINH, VU HUXJ KHIEM, TRAN NGOC HAI, PHAM VAN THAI, N G O TRLTCJNG SON, PHAM CAM PHLTONG, NGUYEN QUANG HUNG, NGUYEN THANH CHUONG,
DOAN XUAN TRLTdNG va cs.
(Trung tdm Yhgc hgt nhdn & Ung budu, Benh viin Bgch Mai)
Tom tdt Muc tieu:
l.Lgp quy trinh chup PET/CT chan doan va mo phong lap k l hoach x? tri cho benh nhan ung thu vom mui hong.
2. Budc dau danh gia vai tro cua PET/CT trong chan doan va lap ke hoach xa tri tren b?nh nhan ung thu vom mui hpng.
Boi tuffng va phuffng phdp nghiin cuu: 20 b^nh nhan chdn doan xdc djnh b^ng giai phlu benh ung thir vom mui hpng, chup PET/CT chan doan, xac djnh giai dogn b?nh va m6 phong lapke ho^ich xa trj trong thdi gian tir thang 7/2010 den thang 01/2011.
Ket qud:
1. Trung tam Y hoc hat nhan va Ung budu B?nh vi?n Bach Mai da xay dyng thanh cong quy trinh chyp PET/CT chdn doan va mo phdng igp ke hoach xg trj cho b?nh nhdn ung thu v6m mui hong,
2. PET/CT rdt co gia trj trong chan doan va xac djnh giai doan b?nh ung thu vom mui hpng:
phat hien khdi u nguyen phat d b^nh nhan di can chua ro nguyen phat; miic dp hap thu FDG (gia trj SUV) cao tgi u vom (SUV trung binb=l 1,83), bgch di can (SUV trung bmh=8,37); thay doi giai doan benh a 38,9% b^nb nhan, giiip quyet djnh phuong thiic dieu tri dung cung nhu tien lupng b?nh tdt hon.
2. PET/CT mo phong giiip xac dinh chinh xac thi tich sinh hpc khoi u BTV; khdng bd sdt di can hgch viing; thay ddi the tich xa tri o 80% cac b?nh nhan so vdi chyp CT md phdng thdng thudng, giam the tich xa trj d 60% benh nhan, han che biln chirng do tia xg. The tich GTV- PET trung binh la 92,3 cm^ so vdi thi tich GTV-CT la 128,4 cm' ( giam 28,1%) Kit luan: PET/CT rat co gia trj trong chdn doan u nguyen phat va di cdn UT vom mui hpng.
Chup PET/CT mo phong Igp ke hoach xa tr; cho benh nhan ung thu vom mui hpng la ky thuat mang lai hieu qua dieu trj cao va an toan cho ngudi b?nh.
I. DAT VAN DE
Ung thu vdm mui hgng (UT VMH) Id mgt trong nhihig b?nh ly ac tinh thucmg gdp nhdt trong cdc ung thu vimg ddu mat co. Benh gap nhilu d cdc nude Ddng Nam A trong dd cd Vi?t Nam. Theo ghi nhan ung thu Ha Ngi, UT VMH dirng hang thii 5 d nam, vdi ty le mdc b?nh chudn theo tudi la 7,4/100.000 ddn, hang thii 8 d nit vdi ty le mdc benh chudn theo tuoi la 4,7/100.000 ddn. Chdn doan UT VMH dua tren cac trieu chiing lam sdng thudng gdp: ngat miii, chay mdu mui, ii tai, dau nda ddu, lac mdt, ndi hgch gdc ham, hgch Idn mdt ben cd; b?nh nhdn thudng den khdm tai cdc ca sd chuyen khoa tai miii hgng, chup CT vung ddu c6 hodc MRI vdm, npi soi vdm phdt hien u. Chdn doan xdc dinh dua tren kit qua gidi phau benh sinh thilt u. Phucmg phdp dilu tri co ban va mang lai hieu qud Id xg tri. Xg tri dugrc chi dinh cho
f{Qi nghi Khoa hgc vd Cdng nghi hgt nhdn todn qudc idn thir IX, Ninh Thudn 18-19/8/2011 621
ph§n Idn cdc benh nhan ngay cd giai doan IV khi chua cd di cdn xa. Viec xdc dinh cac thi tich xa di GTV, CTV, PTV trong Igp ke hoach xa tri tit trude van d\ra tren phim CT md phdng.
Chup PET (positron emission tomography) Id phuang phap chup hinh dua tren sir tap trung F-18 FDG vdo cac td chiic khdi u tren co sd nhiing s\r khdc bi?t vl sinh ly hgc va chuyin hda giiia khdi u vd td chiic lanh. Qua trinh trao ddi chdt tgi cdc khdi u tdng cao ban so vdi tl chiic lanh do dd nhu cdu protein, glucose cao ban. Nhung thay ddi chiic ndng diln ra sdm hon nhiing thay ddi ve cdu tnic gidi phau. Vi the PET giiip phat biSn khdi u, cdc tdn thuang di cdn, cdc ung thu tai phdt sdm bon cdc phuong phdp chyp hinh thdng thudng. Hinh PET/CT Id hinh dnh ket hgp giGa hinh PET (hinh dnh chuyen hda, hinh anh chiic ndng) vdi hinh CT (hinh dnh cdu tnic, giai phdu) cho chiing ta hinh anh sdm, sac net, rd rang, chinh xdc Clia khdi u ciing nhu cdc ton thuang di can xa. Cdc nude phdt trien tren the gidi da sdm dp dyng ky thudt chup PET/CT de chdn dodn, xdc dinh giai dogn, phdt hien tdi phdt sdm cdc b?nh ung thu trong dd cd ung thu vimg ddu mat cd. Ngodi ra neu sir dung hinh dnh PET/CT mo phong thay cho hinh CT md phdng sg cho chiing ta cac the tich xg trj chinh xdc ban, hudng chiim tia xg tap trung vao dung khoi u, gidm lieu biic xg cho cdc co quan Idnh xung quanh, do do xg tri se mang lai hi?u qua cao hon, hgn che bien chiing.
Tmng tdm Y hgc hgt nhdn vd Ung budu (YHHN&UB), Benh vien Bgch Mai da tien hanh chup PET/CT nhu mgt ky thudt chdn dodn thudng quy tir cudi ndm 2009 va den nay da chyp dugc cho ban 1200 benh nhdn. Tir thdng 1/2010 trung tdm ciing iing dung chup PET/CT m6 phdng dl ldp kl hoach xa tri cho cac benh nhdn ung thu, din nay da cd ban 200 benh nhdn ung thu cac loai dugfc xa tri tren ke hogch su dung hinh dnh PET/CT md phdng. Ket qua ban dau cho thay hieu qud dilu tri cao, cdc bien chiing do xg tri it hon. Nghien ciiu nay dugc tien hanh vdi cdc muc tieu: xdy dung quy trinh chup PET/CT chdn doan vd md phdng lap ke hogch xg trj cho benh nhdn UT VMH va budc ddu danh gia vai trd ciia PET/CT trong chdn doan vd lap ke hoach xa tri cho benh nhdn UT VMH.
II. DOI TUONG vA PHUONG PHAP NGHIEN CUU:
1. Ddi tugng NC: 20 benh nhdn chdn doan xdc dinh ung thu vdm miii hgng, dugc chup PET/CT chdn doan, xdc dinh giai dogn benh va md phdng lap kl hoach xg tri tgi Trung tdm Y hpc hat nhan va Ung budu - Benh vien Bach Mai trong thdi gian tir thdng 07/2010 din thdng 01/2011.
2. Phuong phap nghien ciiu: Nghien ciiu thudn tap phan tich tiln ciiu.
3. Quy trinh nghien ciiu:
BSnh nhdn vao vien: chan doan xac dinh (sinh thiet chdn doan md benh hgc) -^ Ddnh gia giai dogn (ldm sang) -> Chup PET/CT -> Xdc dinh lgi giai doan benh -> Lira chgn phucmg phdp dilu tri: xg tri, cd thi kit hgp hda chat -> Lap kl hogch xa tri tren hinh PET/CT md phdng -> Tien hanh dilu tri -> Theo ddi, ddnh gid ket qua dieu tri (lam sang, CT, MRI, PET/CT).
4. Thudc phdng xg va thilt bi sir dung:
- Dung dich F18-FDG do Trung tam Cyclotron benh vien 108 sdn xudt.
- May PET/CT Biographe 6 ciia Siemens, thilt bi laser djnh vi md phdng - Phdn mIm lap kl hogch xg tri Prowess Panther.
622 Hdi nghi Khoa hgc vd Cdng ngh? hgt nhdn todn qudc idn thu IX, Ninh Thugn 18-19/8/2011 - May gia tdc tuyen tinh LINAC Primus Siemens.
5. Cac ngi dung ddnh gid ket qud nghien ciiu:
5.1. Quy trinh chup PET/CT chdn doan va mo phdng lap kl hoach xa tri cho benh nhdn ung thu vdm mui hpng.
5.2. Budc ddu danh gid vai trd cua PET/CT trong chdn doan va xdc djnh giai doan b$nh.
5.3. Budc ddu danh gid vai trd cua PET/CT md phdng Igp ke hoach xa tri.
6. Xu ly sd li?u: bang phdn mem SPSS 15.0.
III.KET QUA VA B A N LUAN
1. Quy trinh chyp PET/CT chan doan va mo phong lap ke ho^ch \^ trj cho bfnh nhan ung thu vom hgng
1.1. Chuan bi benh nhdn: benh nhdn duoc thdm khdm ldm sang, lam cac xet nghiem can thiet, vdi chdn dodn la UT VMH, cd chi dinh xa tri.
1.2. Chup PET/CT: vdo ngay chup PET/CT b?nh nhdn dugc x^t nghiem dudng huyet (dudng mdu phdi nhd ban 7,0 mmoI/1), mach, huylt dp, nhiet dg, chilu cao, cdn nang; ldm mat ng md phdng cd dinh vimg d4u c6, sau dd dupe tiem phdng xa F-18 FDG vdi lilu 6-12 mCi (0,15 mCi/kg cdn ngng); sau tiSm 45-60 phiit bSnh nhdn duac dua ISn mdy chup PET/CT cd he thdng laser dinh vi vd giudng may phii hgp vdi giudng mdy ciia may xg tri gia t6c.
1.3. Phdn tich ket qua chup PET/CT dua trSn phan mIm phdn tich, xac dinh cdc thdng sd Clia u, hgch di cdn, tdn thuong di can xa (vi tri, sd lupng, kich thudc, miic dp hdp thu FDG - ddnh gid qua gid tri SUV).
1.4. Lgp kl hogch xa tri trSn PET/CT: xdc djnh cac thi tich xg tq BTV (thi tich khoi u sinh hgc) cdn ggi la GTV-PET, CTV vd PTV, lgp cac trudng chilu, kilm tra lilu chilu;
chuyen kl hoach sang may xa tri gia tdc, kl hogch se dupe kiSm tra lai tren phantom (qud trinh QA), khi ke hogch dilu tri dat yeu cdu se tiln hanh dilu tri cho b^rih nhan.
1.5 Dieu tri bdng may xg tri gia tdc tuyin tinh LINAC.
2. Vai tro cua PET/CT trong chan doan va xdc djnh giai do^n bfnh:
2.1. Miic do hdp thu FDG (do bdng gid tri SUV):
Ton thuang U Hach di can
SUV trung binh 11,83±3,52 8.37±4,18
SUV min 2.96 2.56
SUV max 19.21 19.95
T6n thucmg u va hach iiu co gia tri hSp thu FDG cao, diSu nay chiing to miic d$ hap thu FDG manh cua cac tdn thirong ac tfnh viing diu m?t. Giup dl d4ng phat hien nhOng t&n thuong nay cho du ki'ch thuoc nho, ddng thcri su chenh lech ve mile dp hip thu cua u v4 mo lanh xung quanh cao giup xac djnh ranh gioi u ro, cac thS tich x? tn chinh xac trong IJp ki hoach dieu tri.
2.2. Phan loai giai doan truoc va sau di^u tri:
Trong 20 benh nhan thuoc d6i tugng nghien ciiu, c6 2 b$nh nhan chan doan ung thu di cto hach c6 chua iB nguyen phat, sau khi chup PET/CT phdt hi$n u nguyen phat t?i vom hong.
Trong s6 18 benh nhan con lai:
Phan loai giai doan truac khi chup PET/CT:
H^i nghi Khoa hgc vd Cdng nghe hgt nhdn tgdn quic lin Ihi TX, Ninh Thudn I8-I9/8/2011 623
Giai doan N Ty le %
1 2 11,1
IIA 2
11,1
IIB 6 33,3
III 6 33,3
IVA 2 11,1 PhSn loai giai dojn sau chvp PET/CT
Giai doan N Tyle%
I 1 5,6
IIA 2 11,1
IIB 5 27,8
111 6 33,3
IVA 2 11,1
IVB 1 5,6
IVC 1 5,6 S6 b$nh nhdn cd thay ddi giai dogn b?nh Id 7/18=38,9%. T;^ le phdt hien hgch di can la 4/18=22,2% (1 benh nhdn giai doan IIA phat hien them hach di cdn chuyin giai dogn IIB, 2 b$nh nhdn giai dogn IIB phat hi|n hach di cdn ddi ben chuyen sang giai dogn III, 1 benh nhdn giai doan III phat hi?n hgch di cdn ho thupng ddn chuyen giai dogn sang IVA).
Viec xdc dinh chinh xac giai dogn b?nh rdt cd y nghia trong viec l\ra chon phdc do dieu tri cung nhu tien lupng benh.
PET/CT cd dg nhgy, dp ddc hieu vd dg chinh xdc cao ban so vdi cdc ky thudt chdn doan hinh anh khdc. Theo Lang O, Schneider K, Breuning A FDG-PET cho ung thu ddu mat cd cd dp nhgy 86% vd do ddc hieu 87% trong chdn dodn xdc dinh khdi u nguyen phdt, di can hgch viing va di cdn xa (5). Trong m§t nghien ciru khdc vdi 48 benh nhdn, Hannah vd cpng sir dua ra kit ludn rdng FDG PET cd dg nhgy 82% va do ddc hi?u 94% phdt hien di cdn hgch cd, so sdnh vdi dO nhay 81% va dd d^c hieu 81% cua CT (4). Nghien ciiu ndy cdn mgt sd luang b?nh nhdn du Idn dl xdc dinh dd nhay va do dgc hieu ciia PET/CT.
3. Vai tro ciia PET/CT mo phong l$p ke hoach xa trj
Tren hinh anh CT md phdng cho phep xdc dinh duoc 3 thi tich la GTV (gross tumor volume), CTV (clinical target volume), PTV (planning target volume); tren hinh PET/CT mo phong cho chiing ta tham 1 thi tich la BTV (biologic target volume) hay cdn ggi Id GTV- PET. Id hinh anh khdi u d miic dg chuyin hda, miic dg te bao nghia la toan bg the tich cac te lao ung thu tdng chuyin hda gdm cd nhirng vung chua thdy biln ddi vl cdu tnic cung dugc
624 Hdi nghi Khoa hgc vd Cdng nghi hgt nhdn todn qudc idn thir IX, Ninh Thudn 18-19/8/2011 phat hien. Do vdy, hinh anh PET/CT phdt hien tdn thuong chinh xdc vd sdm ban hinh dnh giai phau ma cac phuang tien chdn doan hinh anh thdng thudng mang lgi; ngoai ra BTV cdn dua ra mat do te bdo ung thu trong the tich dieu tri.
Tren hinh cho thdy tren hinh dnh PET/CT chiing ta dl dang xdc dinh dupe thi tich khdi u vdi ranh gidi ro rdng. (Dudng mau vdng: GTV vd BTV; dudng mdu dd: CTV) Tir dd viec lap kl hogch xa tri chinh xdc ban va mang hieu qua cao hon trong dieu tri.
Chup PET/CT mo phdng lap kl hoach xg tri cd uu dilm han chyp CT md phdng d chd:
- PET/CT xdc dinh chinh xdc ria tdn thuong ban CT trong nbiSu trudng hgp ranh gidi khd xdc dinh giua khdi u vd td chiic xung quanh (K vom, K thanh qudn, K thuc quan, giua u phdi vdi td chiic phdi xep). Dilu nay rdt cd y nghia de xac dinh thi tich khdi u thd GTV, giiip cho viec xa tri chinh xdc vao td chiic u ddng thdi tranh xg vao cdc td chiic Idnh tinh nhdm ndng cao hieu qua cung nhu giam bdt cdc tac dung phu do tia xg.
- Khdi u kich thudc nhd, khdng nhin thdy tren CT nhung cd the phat hien dugc tren PET/CT do tinh chdt kit hgp bd simg cho nhau giiia hinh dnh PET va hinh anh CT tren ciing mgt he thdng. Vi dy khdi u vdm nhd, U thuc quan nhd, K phdi the thdm nhiem phi qudn giai - PET/CT ddc biet cd gid tri trong viec phdt hien di cdn bach vung ma tren CT kho phat hien dupe ddc biet hgch cd kich thudc nhd. Dieu ndy rdt quan trgng ldm thay ddi GTV, thay ddi lilu xa tu xg du phdng sang xa dieu tri, lara tang khd nang kiem sodt tgi viing, ndng cao hieu qua dieu tri.
Trong nghien ciiu ndy chiing ta thdy:
So sanh GTV-PET voi GTV-CT (Nguong thay d6i
> 25% thi tich) Thay doi Tan so 16/20
%
80,0
Tang (%) Giam (%) 20 60,0
PET/CT phat hien them ton thuang so vol CT (di can hach)
Tan suit 4/18
Ty le % 22,2
Sir dung ky thuat PET/CT mo phong lam thay d6i 80% thS tich GTV (thi tich khoi u tho), trong do 20% lam tang th6 tich GTV, va 60% giam the tich GTV, Cac trucmg hop GTV tang ciing chi yiu la do PET/CT phat hiSn them di can h?ch viing.'Tit do, viec lap ki hoach xa tri voi PET/CT mo phong duoc chinh xac hon, khong bi sot cung nhu giiip phan lieu xa du cho cho ton thuong; dong thai tranh dugc heu xa khong cin thilt vao cac mo lanh xung quanh, han che biln chiing do tia xa. Theo nghien ciiu cua Paulino tren 40 benh nhan ung thu diu mat c5, cho kit qua thay dii thi tich GTV a 93% sl benh nhSn, trong d6 GTV tang d 18%vagiama75%.
So sanh thi tich GTV-PET va GTV-CT:
X±sd
GTV-PET (BTV) 92,3±12,5cm'
GTV-CT 128,4±18,7cm'
Hgi nghi Khoa hgc vd Cdng nghe hgt nhdn tgdn qudc lin thi TX, Ninh Thudn 18-19/8/2011 625
Nhu vay thi tich GTV-PET trung binh giam hon so vol thi tich GTV-CT trung binh.
Dilu nay co nghia la giam thi tich xa tri xuIng, han chi lilu xa vao cac tl bao lanh xung quanh, giam biln chirng. Z.Xiang trong mpt nghien ciiu vai 17 b?nh nhan lap kl hoach xa tri tren PET/CT cho kit qua: PET/CT da thay ddi giai doan TNM a 7 (41%) benh nhan, thi tich BTV (PET/CT-GTV) va CT-GTV khac nhau (84,3 cm^ va 116,2 cm') co y nghia thing ke, PET/CT giup xac dinh giai doan va the tich dich xa trj chinh xac hon (6).
Hieu qua dilu tri: do thoi gian con ngan, mot so benh nhan van dang trong qua trinh dilu trj nen chua the c6 ket qua cu thg. Da co 6 benh nhan kit thiic qua trinh dilu tri, di kham lai va chup PET/CT diu cho kit qua rit tit: 6/6 dap ling hoan toan (u va hach tan hit), biln chirng kho mieng 2/6 b?nh nhan a mirc do nhe.
IV.CA LAM SANG MINH HOA:
1. Ca lam s^g 1. Phdt hiin u nguyen phdt a benh nhdn UT di cdn hgch cd chua ra nguyen phdt: BN Ng. T. B., nii, 48 tuoi, UTBM khong biet hoa di can hach co CRN?, soi v6m khong phat hi?n thay ton thuang. Tren hinh anh PET/CT ton thuang duoi niem mac thanh vom Uai tang hap thu FDG manh.
2. Ca lam sang 2. Gid tri chin dodn di cdn xa giup xdc dinh giai dogn cua PET/CT:
BN Ng. Thanh B., nam, 16 tuli: chin doan: Ung thu vom, GPB: UTBM khong biet h6a, Intdc chup PET/CT benh nhan dugc danh gia K vom T4N0M0; kit qua chup PET/CT:
T4N1M1 (di can hach goc ham va di can xuang cimg)
626 Hdi nghi Khoa hgc vd Cdng nghe hgt nhdn todn qudc idn thu IX, Ninh Thudn 18-19/8/201]
3. Ca lam sdng 3. Gid tri ciia PET/CT trong lap ki hogch xg trf:
BN nu, 52 tudi, chdn dodn K vdm T3N0M0; Hda xg tri ddng thai.
3D 1 D..™s„,. 1 £•,«,,
ff E ,ll\
" ' - _ ) I S —
•=• ^ _ i r«
r r JP, [S ; r r BK |« !
HQi nghi Khoa hgc vd Cdng nghe hgt nhdn todn quic lin thi IX, Ninh Thudn 18-19/8/2011 627
Hinh PET/CT giup xac dinh chinh xac thi U'ch xa tri BTV (duong mau do), tir do xac djnh dugc thi tich CTV (duang mau xanh), lap cac truong chilu va tinh Ulu chilu vao khii u (cac duong dong lieu bao sat the tich CTV, tranh dugc cac tuyen nuac hot mang tai hai ben, hjn chi lilu v4o xuong ham ciing nhu nhu mo nao.
4. Ca lam sang 4. Hieu qud xg Iri vai PET/CT md phdng vd ddnh gid kit qud diiu trj ciia PET/CT:
BN nam, 54 tuli, chin doan K vom T2N1M0, tiln hanh hoa xa tri, kit thiic lieu trinh dilu tri 4 thang sau chup PET/CT danh gia hieu qua dilu tri:
Tmoc dieu ui: khii u thanh vom trai va hach Sau dilu tri 4 thang: khong con thiy khii u goc hta Udi tang hip thu FDG. vom va hach goc ham tang hip thu FDG.
V.KETLUAN
1. Trung tam Y hgc hiit nhan va Ung buou Benh vien Bach Mai da irng dung thanh cong quy trinh chjip PET/CT chin doan va mo phong lap kl hoach xa tti cho benh tihan UT VMH, Hen hanh dieu trj cho nhilu b|nh nhan mang lai hieu qua cao.
2.PET/CT rat co gia tri ttong chan doan va xac dinh chinh xac giai doan benh trong UT VMH: phat hien khoi u nguyen phat cho benh nhan ung thu di can chua ro nguyen phat; mirc llj hap thu FDG (gia tri SUV) la rit manh dii vol tin thuong u vom (SUV ttung binh=l 1,83) Cling nhu h?ch di cSn (SUV trung binh=8,37) giup dl dang phat hien tin thuong; thay dii giai ilo?n b^nh it 38,9% b$nh nhan sau khi chup PET/CT, giiip xac dinh diing phuang thirc dilu tti Cling nhu giiip tien lugng benh tit han.
2. PET/CT mo ph6ng rdt co gia tri ttong lap kl hoach xa tri UT VMH: giiip xac dinh chinh xac thi tich khoi u sinh hgc BTV; khong bo sot hach vimg; thay doi thi tich xa tri a 80% cac bfnh nhan so voi chup CT mo phong thong thucmg, giam the tich xa tri 6 60% b$nh Dli^ giiip giam Ulu buc x? khong cin thilt vao cac mo lanh xung quanh, han chi biln Chung. Thi tich GTV-PET trung binh la 92,3 cm' so vol thi tich GTV-CT la 128,4 cm'
628 Hdi nghi Khoa hgc vd Cdng nghi hgt nhdn todn qudc idn thir DC. Ninh Thudn 18-19/8/2011 VI. TAI LIEU THAM KHAO
[1] Phan Sy An va cdng su: Bai giang Y hpc bat nhdn, nhd xudt bdn Y hgc Ha Ngi, 2009, tr.
100-106.
[2] Nguyen Bd Dire: Chan dodn va dieu tri benh ung thu, Nhd xudt ban Y hgc Hd Ngi, 2009, tr. 100-111.
[3] Mai Trpng Khoa, Trdn Dinh Ha, Phan Sy An, Le Chinh Dai va cdng su (2010): iTng dyng ky thudt chup hinh PET/CT trong ung thu tai Trung tdm Y hpc hgt nhan va Ung budu Benh vien Bach Mai, Y hgc thanh phd Hd Chi Minh, trang 570-579.
[4] Koshy M, Paulino AC, Howell R, Schuster D, Halkar D, Davis LW: F-18 FDG PET-CT fusion in radiotherapy treatment planning for head and neck cancer. Head and neck cancer 2005, 27(6): 494-502.
[5] Lang O, Schneider K, Breuning A et al 1999 Head and neck cancer: value of F-18 FDG in primary staging anhd suspicion of recurrence [abstract] J Nucl Med 40 (5 SuppI):63P.
[6] Z.Xiang: PET/CT fusion in radiotherapy treatment planning for head and neck cancer.
Journal of Clinical Oncology, 2009 ASCO Annual Meeting Proceedings (Post-Meeting Edition).Vol 27, No I5S (May 20 Supplement), 2009: el7046
