Y H p c T P . H b C h i M i n h * T a p 1 8 * S d 1 * 2 0 1 4 N g h i e n c i i u Y h p c
VAI TRO SIEU AM TAI C H 6 TRONG PHAU THUAT CAT GAN DIEU TRI UNG THU" GAN NGUYEN PHAT
Ngo Viet Thi *, Bui Manh Cdn*, Nguyen Cao Cuang*, Nguyhi Hdi Dang**
TOMTAT
Datvmt de: OVict Nam,uiig thu gan nguydi phdt khd plio bidi. tidi luong xau. Phiu thuat cdt gan Id phuang phdp duy nhdt co the dmi tri tan got. Sieu am trong mo Id mot phucmg tien rai hieu qud gidp cho phdu thuat vidi ti-ong phdu thugt cdt gan.
Muc tieu: Ddnh gid hieu qua ciia sidi am trong ph&u thudt dtgan dieu tri ung thu gan nguydi phdt.
Dot ti^ng - Phuang phdp nghien cdu: Hoi ciru, nw td cdt ngang 93 trucmg hap ung thu gan nguydi phdt duac phau thugt co kdn sidt Sm trang ldc mo tgi berih vien Bhih Ddn tie 01/2(X)8 dai 03/2013.
Kei qud: Sieu am tgi cho'tiong khi moco do chinh xdc tiong phdt hien u Id 94.6%>, do nhay vddodgc hieu trong chdn dodn ung thu la 97.1%o vd 33,3%o. Nhd vdo sidt am trong moco 14%> tneimg hap (13/93) co tliay doi phii hap hem trong kehogdi cat gan vd 18,3%, truinighap (17 '93) xdc dudi dugc bd dt an todn.
Kei ludn: Sidi dm tiong moan todn, nhanli chdng, dio thong tin chinh xdc hudng ddn phdu thudt vidi ngay trang luc mo, ldm tang hieu qud cua phdu thugt cdt gan dieu tii ung thu gan nguydi plidt.
TH khoa: sidi am tnmg mo'- phau thugt cdt gan - ung thie^n nguydi phdt.
A B S T R A C T
THE VALUE OF INTRA-OPERATIVE ULTRASOUND IN UVER RESECTION IN TREATMENT OF PRIMARY UVER CANCER.
N g o Viet Thi, Bui M a n h C o a N g u y e n Cao C u o n g N g u y a i Hai D a n g
* Y H o c TP. H o Chi M i n h * Vol. 1 8 - N o 1-2014: 111 - 116
Backgrcmnd: In Vietiunn, primary liver caiuxr is common, poor prognosis. Uver resection is the aidy mdhod may idtimatdy cured. Intra-operative ultrasound is a very effective mean cfhelphig surgeons in liver resection.
Objective: To assess the c^divaicss of intra-operative ultrasound in liver resection in the tieatineiit of primary liver cancer.
Method: RetrospedizfC, cross-sectional descriptive, 93 cases of primary liver cancer underling liver resectiomaith intra-operative ultrasound at Binh Dan Hospital from 01/2008 to 03/2013
Results' Intra-operative ultrasound liasaccuracy in detectbig tumor: 94.6%, the saisitivity and spedfidty of cancer diagnosis is 97.1% and 333%. Due to intra-operative ultrasound, 14% of cases (13/93) bavesuitdle dianges in plan cf liver resection and 133% of cases (17/93) identify safe margins cf resection.
Conclusicm: hitia-operative ultrasoundsafe, fast, and gives accurate information to guide the surgeons during surgery, mcreases the effidaicy ofthe Ihvr resection m tieatmait of primary liver cancer.
Key zoards: intra-operative ultiasound - liver resedion - primary liver cancer.
D A T V A N D E ^ ' ^ * " ^ ^ chting ta, u n g t h u g a n n g u y e n p h a t k h a p h o bien, tien i u o n g r a t xau. T h e o t h o n g k e U n g thu g a n n g u y e n p h a i l i loai u n g t h u ^ ^^^ ^^ j ^ _ ^ ^ . ^ ^^^ ^ ^ ^ - n , ^ pf,g xuat p h a t t u t e b a o g a n h a y t e b a o o n g mat. O ^J-^ , ^ j ^ ^ ^ ^^ ^ ^ ^ ^ ^ . ^ p ^ , ^ g ^
*Khoa ngoai Tong quat, Benh vien Binh Dan ** BV Dai hoc Y khoa Pham >Jgoc Thach Tdcgia lien lac BS.Nguyen Hai Dang DT. 0937777936 £miiJ7: drhaidang!?'gmaii.com
Nghien cihi Y hpc
hang ^ u trong cac loai ung thu o nam gioi (21,4%), dung hang thu sau o phai nii va diing thii hai cho ca hai phai'^'.
Trong nliieu th^p nien qua, van chi co mot phuang phap dieu tri chii yeu la cat gan*^-^* Phau thuat cat gan la phuang phap uu viet co the dieu tri tan goc doi vod ung thu gan nguyen phat neu thuang ton con khu tni va duoc phat tiien somP*.
Thuc te, ty le cat dugc gan rat thap, chi 16,1- 343%*^''-^'"- Cac tac gia trong nuoc ghi nhan ty le nayla5-20%i"6-i5).
Du da CO cac phuang tien can lam sang ve hinh anh hpc truoc mo nhung bac si phau thuat con kha phan van khi hoach dinh gioi han duong cat bo gan co khoi u ngay trong khi mo.
Ngoai ra, su dung sieu am tai cho giiip phat hien nhung u gan nho hon 1cm ma sieu am truoc mo kho phat hi^n'^>. Sieu am tai cho trong khi mo con giiip xac dinh so lupng cac u, loai tru u.
Tuy da CO nhieu cong trinh nghien cuu trong va ngoai nutjc ve ung thu gan va phau thu^t cat gan do ung thu, nhung nghien cuu ve tinh hieu qua Clia sieu am tai cho trong chan doan ung thu gan con rat it. Dac biet o Vi#t Nam, hinh thiic nay con moi chua duoc pho bien.
Thi^c hi^n nghien cuu nay, chiing toi mong muon gioi thieu mpt phuong tien gop siic kha hieu qua cho bac sT phau thuat co chi diem cu the trong gioi han cat gan. Nhung u v% tinh dupe phat hien nho sieu am tai cho trong khi mo la mot ket qua rat khich le ciia de tai. Chiing toi con xac dinh kha nang chong chi dinh phau thuat khi thiJc te' ghi nhan ctia sieu am tai cho khi mo.
Muc tieu nghien cuu
Danh gia kha nang phat hien cac u aia sieu am tai cho trong khi mo.
Danh gia do nhay va dp dac hieu phat hien ung thu gan ciia sieu am trong mo.
Danh gia vai tro sieu am trong mo trong viec cat gan dieu tri ung thu gan nguyen phat.
E)6lTLfaNG-FHU'ONGITIAPNGHIEN CUlJ Phuong phap nghien cuu
Hoi ciiu, mo ta cat ngang bao cao hang loat ca.
Thai gian va dia diem nghien cuu Benh vien Binh Dan tu 01/2008 deh 03/2013.
Dbi hrpng nghien cmi Tieu chuan chgn benh
Tat ca cac benh nhan dupe chan doan ung thu gan nguyen phat dupe phau thu?t tai benh vien Binh Dan. Benh an luu tru' phai ^y dii cac yeii to nghien cuu theo benh an mau, dac biet la ket qua giai phau benh.
Tieu chum loai trie
B?nh nhan khong dong y tham gia nghien ciiu hoac ho so benh an khong day dii.
Xu ly ket qua nghien cuu
Cac so lieu lam sang duoc luu trii va tinh toan bang phan mem SPSS 18.0.
KET QUA NGHIEN CLTU
Trong thoi gian tii 01/2008 deh 03/2013, chiing toi da thuc hien duoc 93 truong hpp cSt gan do ung thu nguyen phat co kem sieu am trong liic mo dti ti^u chuan chpn vao mau nghien ctiu.
Dac diem benh nhan
Tuoi
Trung binh: 54,22 ± 1,96. Liia tubi 50-59 tubi chiem nhiHu nhat.
Giai
Nam chiein 72,0% (67 truang hpp), nii chiem 28,0% (26 truong hpp).
Ty le nam/nii = 67/26 (2,6/1).
Tbn thuong dai the
Viiriu
U gan phai: 63 TH: 67,7% (Ha phan thuy 5,6,7,8).
U gan trai: 27 TH: 29% (Ha phan thuy 2,3).
Y Hpc TP. Hb Chi M i n h * Tap 18 * Sb 1 * 2014 Nghien cuu Y hpc
U gan 2 thuy. 3 TH: 3,3%.
Kich thuac vd so lugng u
Trong 93 benh nhan chiing toi tong cpng 112 khbi u CO phan bb theo kich thuoc u nhu sau:
Bdng 1: S6'lu(;nig u - kjdi thudc u 56 l i p g n g ^ " " " - ^ ^
1 2
> 3 - 5 T i n g cpng
< 5 c m 57 (50,9%) 11(09,8%) 7 (06,3%) 75 (67%)
> 5 c m 35(31,2%)
2(01,8%) 0 (00,0%) 37(33%)
9 2 ( 8 2 1 % ) 13(11,6%) 7 (06,3%) 112(100%) Nhan xet ty le benh nhan chi co mpt khoi u chiem cao nhat cho ca hai truang hpp u nho hon hay Ion hon 5cm, voi ty le lan lupt la 76,0% va 94,6%.
Ket qua danh gia dp chinh xac giiia sieu am tnroc mb va sieu am trong mb
Bdng 2: Kei qud phdt hien u ciia sidi dm trong mo' Sieu am tnjcrc mo
Sieu am trong mo
Phat hien u Khdng F ^ t hien u
Phat h i f n u 95 106
K h o n g phat h i e n u 17 6 Ung t h i r
100 3
K h 6 n g u n g thiP 6 3 Dp chinh xac aia sieu am trong mb trong viec phat hien u la 106/112 = 94,6%.
Dp nhay phat hi^n ung thu gan aia sieu am trong mb: 100/103 = 97,1%.
Dp dac hieu chan doan ung thu ciia sieu am trong mb: 3/9= 33,3%.
Bdng 3: Kei qud ddi chieii do chinh xdc phdt hien u huyd khdi tinh mqch cim (thrombus tumor) giira sidi dm trong mo'-sidi am tnedc mo
So benh nhan co u huyet kh6i tac finh mach ci/a phu
t)p chinh xac {%)
SA t r o n g m d 14 66,7
S A t n r o v m d 4 19 Ket qua co 21 truong hpp co u huyet khbi finh mach ciia phu tren giai phau benh ly va ton thuang liic mb. Benh nhan co huyet khoi Imh mach Clia chinh thi khong co chi dinh cat gan, u huyet khbi nhanh finh mach aia thi can phai lay bo nhanh finh mach co huyet khoi.
Dac diem phlu thuat cat gan
Tat ca cac truang hop nghien ctiu aia chting toi (Jeu dupe thiJc hien eat gan co kehoach:
Cat gan nho (eat ha phan thiiy, cSt rpng each ria u > 1cm): 88,2% (82 BN).
Cat gan Ion (cat phan thiiy hay eit 1 ben gan): 11,8% (11 BN).
Bdng4: Hieu qud ciia sieu dm tiong n
1 2 3 4
N h o m Khong ph^t hien sang thuiyng moi
Khdng thay doi I d hoach c i t gan Khong phat hien sang ^u'cmg mdi
H S trp ke hoach cat gan Phat hien sang t h y o n g mon.
Khong thay ddi ke hoach c i t gan Phat hien sang thu-ong mon.
Thay doi ke hoach c i t gan S d B N
55/93 17/93 8/93 13/93
T i l f ( % ) 5 9 , 1 % 18,3%
8,6%
14,0%
BAN LUAN
Dac diem mau
THOITheo tac gia Van Tan"^ va Nguyen Sao Trung*''*, Ilia tuoi thuong bi ung thu gan la 51 - 60, trung binh la 52,2 ± 2,5. Tae gia Zhao You Tang''^) ghi nhan liia tubi thuang bi ung thu gan nguyen phat 6 Nhat la 50 - 59 tubi, 6 Hoa Ky la 55-60 tubi.
Trong khao sat nay liia tuoi thuong bi ung thu gan 50 - 59 tuoi, tuoi trung binh la 54,22 ± 1,96, khong co su khac bi^t voi cac tac gia trong va ngoai nuoc. O eae nuoc A chau, ti le ung thu gan eao, va 6 nguai tre ciing cao hon so. voi 6 Chau Au, Chau My.
Giai tinh
Theo ghi nhan eiia chiing toi, nam gioi bi ung thu gan nguyen phat gan gap 3 lan nu gioi.
Ket qua nay phu hpp voi tac gia Nguyen Sao TrungPi' va Zhao You Tangi"!^ Theo tac gia Nguj'en Dai Binh""* ty le nam/nii la 4/1.
Vitriu V a n T & n ' " ' Nguyen Dai B i n h " " '
Chung toi Gan (P)
72,0%
75 8%
67 7%
G a n ( T ) 28,0%
17,2%
29,0%
C a 2 » ) u y 7 0%
3 3%
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Nghien cuu Y hpc
Ket qua ghi nhan ciia khao sat nay phu hop voi ket qua ciia cac tac gia Van Tan''^', Nguyen Dai Binh'"". Co the la do nhu mo gan o gan (P) nhieu hon gan (T) nen kha nang xuat hien ung thu gan nguyen phat 6 gan (P) ciing nhu gan (T).
Tuy nhien, theo tac gia Terence P. Wade"^, khong CO su khac biet ve su xuat hien ciia u 6 cac thiiy gan.
Dai the'
VanT^n'^=' Nguyen Sao T m n g ' " '
N g u y i n Oai Binh'"'' Chiing tdi
l u 84,0%
73,7%
79,7%
8 2 , 1 % Nhidu u
16,0%
21,9%
20,3%
17,9%
Lan toa 4,4%
Cac nghien eiiu ghi nhan dang d^ the ciia mpt khbi u la thuong gap nhat (73 - 90%). Dang dgi the nay rat thuan lpi dieu trj bing phau thuat tiem con hoac TACE. Dang dai the nhieu khbi u chi thuan lpi eho dieu tri phau diu^t hoac TACE khi cac u nay con nam gioi han trong mpt ha phan thiiy, mpt phan thiiy hay mpt thiiy gan.
Ket qua ghi nhan ctia khao sat nay phii hpp vai ghi nhan ciia tac gia Van Tan''^' va Nguyen Dgi Binh"o> Sb li#u ghi nhan ciia tac gia Nguyin Sao Trungf'co su khae bie^ co the do each chpn lua nhom berth duoc nghien ciiu: mau nghien aiu Clia tac gia Nguyen Sao Trung la toan bp b^nh nhan ung thu gan dupe chan doan xac dinh, trong khi mau nghien ciiu nay la nhiing benh nhan ung thu gan co chi dinh phau thugt.
Ban luan vai tro sieu am trong mb trong chSn doan img thu gan nguyen phat Phdt hien vd dinh vi ton thuong trong gan
Chting tdi
M a k u u c h i ' "
Dd nhay (%) 0 6 d | c hieu {%) Od chinh xac (%) Od nhay {%) Dd dac hieu (%) Op chinh xac %)
Sieu am trong md 97,1 33,3 94,6 99 82 97
Sieu am t r u ^ c m d
85,5 89,3 86 76
Sieu am trong mo la mpt phuang tien can thiet trong phau thuat gan, nhat la trong viec xac dinh vi tri cae tbn thuong 6 gan va phat hien cac ton thuang mdi. Nhung u nho xuat phat tu gan
va nhung mach mau, thuong khong the nhin va so tren be mat nhat la 6 benh nhan xa gan. Sieu am trong mb eo the phat hien nhiing not 6 gan <
Smm tiiy thupc tan sbciia dau do va ky nang ciia bac si sieu am. IsJhiing not mdi nay eijng eo ty le dang ke la nhiing nbt ung thu v§ tinh nen chiing nen dugc dieu tri ngay (cat bo hay chich con de hiiy diet u).
Ket qua ve dp chinh xae va dp nhay ciia chiing toi thi tuong duong vdi ket qua ctia tac gia Makuuchi''^, con dp dac hi?u trong nghien a i u oia chiing toi ftiap hon cd the cho rang sieu am thi khong the phan biet giiia cac u ve tinh va di can trong gan aia ung thu gan nguyen phat vdi cac nbt u tai sinh hay tang san.
Ket qua nghien ciiu aia chiing toi cd dp nhay, dp dgc hieu vdi dp chinh xac tiiap hon so vdi aia tac gia Patel NA. Cd le trong nghien ciiu Clia tac gia Patel NA^^'da dung dau do sieu am cd tan sb cao hon de phat hien tbn tiiuong. Con nghien ctiu aia chiing toi la dung (^u do dang thang CO &n so' 7,5MHz de phat hien u gan"^'
Tu khi ky thugt sieu am trong khi mo dupe ap dyng vao trong chan doan va dieu tri phau thuat cat gan do ung thu gan nguyen phat, da co nhiing eong trinh nghien euu so sanh gia tri chan doan xae dinh ung thu gan nguyen phat giiia sieu am trong khi mo va cac phuong phap khac nhu: sieu am trudc mb, chup eat lop vi tinh.
Ke't qua nghien aiu eiia ehiing toi va eae tac gia khad''^ nhan thay rang dp ehinh xac trong phat hien u, dp nhay va dp dac hieu trong chan doan ung thu Clia sieu am trong khi mb eao hon dang ke so vdi sieu am trudc mb.
Phdt hien suxdm lan cua khoi u
Sieu am trong liic mo con giiip su phat hi^n tinh trang tac maeh, xam 1 ^ maeh mau, bieii hien khae eiia sy xam lah ung thu te bao gan nguyen phat la huyet khoi do u (tac finh mach Clia). Viec phat hi?n tic nhanh tmh mgch cira do u giiip cho quyet dinh cat bd phan gan bao gom nhanh tfnh mgch ciia hay thay dbi ke hoach dieu tri neu tae finh mach cxxa d phan gan khac.
Y Hpc TP. Hb Chi Minh * Tap 18 * Sb 1 * 2014 Nghien cuu Y hpc Theo Makuuchi }~). sieu am trong liic phau
thuat giiip phat hien tac tinh mach aia chinh do khbi u d 110/152 trudng hop, chiem ty 1# 72"o.
Trong nghien eiiu ciia chiing toi, ty le phat hien tac tihh mach ciia do khbi u la 66,7%. Ket qua oia chiing toi tuong tu vdi ket qua ctia tae gja Makuuchi va Machi.
Ban luan ve gia tri sieu am trong mb trong vi^c giup cat gan dieu tri ung thu gan nguyen phat
Theo Ming- Hui Fan"^', cd 18% benh nhan thay dbi ke hogch phau thuat cat gan nho nhiing phat hien ciia sieu am trong mb, dan den phau thugt Idn hon d 15% benh nhan.
Trong nghien ciiu ctia chiing toi cd 13 trudng hpp (14%) cd thay dbi ke hoach cat gan nhd vao sieu am trong mo.
Chiing toi cd 17 trudng hap (18,3%) khi mb du khong nhin hay sd thay u, nhung nhd vao sieu am trong mb da giiip chiing toi xac dinh dudng bd cat an toan. Theo MakuuchiP", nhiing khbi u < 5em d benh nhan xo gan khong the phat hi^n dupe bdi nhin va sd khoang 50% benh nhan, tham chi dii cho nhiing khbi u nay da dupe phat hien bang nhiing phuong phap chain doan trudc mb. Sieu am trong khi mo cd the giiip dinh vi lai nhiing khbi u nhu vay.
Theo Grondona*^*, si^u am trong mb cd vai trd rat hiiu ich trong viec phac hpa vimg eat trong trudng hpp cae sang thuong khu trii d phan thiiy trai ben. Dae biet, d benh nhan ed khdi ung thu gan nguyen phat cd bd khdng xae dinh tiep xiic vdi nhanh finh maeh ciia d hg phan thiiy III. Nhd sieu am trong khi mb chiing ta cd the xac dinh ro mdi Uen quan giai phau giiia sang thuong va cac eau tnic gan trong nhu md.
Sieu am trong khi mb cho thay mbi lien quan Clia khbi u va tinh mgch ciia va cac nhanh tinh mach gan va do dd xac dinh phan thuy hay ha phan thiiy ehiia khoi u. Hon niia, kha nang phan bi?t cac khbi u va mgch mau va eae dudng c^t eat gan Clia sieu am trong mb hudng chiing tdi phat
trien ky thugt cat gan hg phan thiiy cd he thbng.
KETLUAN
Qua nghien ciiu vai trd sieu am trong mb khi phau thuat cat gan do ung thu nguyen phat tren 69 benh nhan tai benh vien Binh Dan (tir thang 01/2008 d a i tiiang 12/2009), ehiing tdi cd mot sb ket luan nhu sau:
Sieu am tgi chd trong khi md" ed:
- Dp chinh xac trong phat hien u: 94,6%.
- Dp nhay trong chah doan ung thu: 97,1%.
- Dp dac hieu trong ehah doan ung thir 33,3%.
Vai tro sieu am trong mb trong viec cat gan dieu tri ung thu gan nguyen phat:
- 14% trudng hpp (13/93) cd thay doi ke hoach cat gan phii hpp hon.
-18,3% trudng hpp (17/93) khi mb du khong nhin hay sd thay u, nhung nhd vao sieu am trong mb da giiip chiing tdi xae dinh dudng bd eat an toan.
TAI LIEU THAM KHAO
1 a-Serag HB et al (2003) Tiu contmiiing increase m Ihe maiinice cf hepatixeOi^r carcbwma in the Umted Stales. An update Ann Intern Med 2003:139:817-823.
2 Grodona P, Meola C Horts F (2008) Utirasound-guided Iwer resKtwii. Early expenence m adistrkt general htspital. Journal ai Ultrasound, pp 162-167
3 Hanazaki BC, Kajikawa S, Shiitiozawa N, Shimada K, Huagun M, Koide N, Adachi W, Amaiw Jun (2001) Hepatv rtfectttmfar large hepatocellular cardivrma. The Amencan Joumal of S u r g s y ISl (2001) 347-353
4 Krause D, Guy F (2007). Les tumeurs h ^ a b q u e s de I'echop^phie a I'lRM, Department de radiologie et imageie medicale Chu Dijon, pp 1-79.
5 Lu P, Wang J, Wu Y (2001), Sigitificanct (fprospecttvefetllmi^up rnhort stiidi/ in daignosis and treatment of prmtary hepatv anuxr at>\img HBsAg mrrinjZhorghua Yi Xue Za Zhi 2001 Jul 253I(l-!);856-9 (Abst).
6 Makuuchi M et al (1997) HepaloceUular carcnioma Maingot's Abdominal Operations Appleton k Lange \ ' d n. 10* Editic«\
1997, pp 1561-1590
Makuudu M. Hasegawa H. Vamazaki S(1987). The use rf operative ultrasound as an aid to liver resection m patients with hepatocellular cardnoma.Worid J Surg. 11, pp. 615- 621.
8 Ming-Hui F a a Al&ed E Chang (2002) Fjesectim vflwer tumor bxtmical aspects Surgical Oncologj-lO.pp 139-152.
9 NguyHi Chah Hung, Tran Nguj'en Ha, Vo Ngoc Due, Hoarg Thj MaiHio), Nguyen Trung Hiep (2001) Ungthuganngui/en phdt dich lehoc, dian dodn va dieu tri Y hgc tiianh pho Ho Chi
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014
Nghien ciru Y hpc Y Hoc TP. Hb Chi Minh * Tap 18 * So 1 * 2014
\finH tap 5, phu ban 4,2001.237-244.
Nguyen Dai Binh, n \ 3 m Duy Hien (2006). Soiig them bai ndm sau dieu tn uug thu bi?ii mo Ifbdo gan tai benh vien K. Tap chi y hi?c Tp HCM so dac biet chuyen de Ung buou hoc tap 10(4), tr 203-208.
Nguyin Sao Trung \a c^mg sy (2004) Ung Ihir gan ngui/eii phat ddc dian giai ph&u bhih va lam sang. T?p chi y hpc Tp HCM so d^c bi?l chuyen de Ung buou hpc t | p 8(4), tr 45-50 Patel NA, Roh MS (2004) Utiht;' of intraoperative liver ultrasound. Surgical dinics of North America, Vol 84(2), pp.
513-524.
Tang Z. Curley SQ (2004), Uver ameer. UICC Manual of Clinical Oncology, 8* Edition. John Wiley & Sons hic, pp 405- Teo EK, Fock KM (2001) HepatoalUdar n perapQTfireDigDis 2001;19(4).263-8fylhsf)
Van Tan, Hoang Danh Tan (2005). Ung thir duimg mat Irong
gan. T?p chi y hoc Tp HCM so d^c b i ^ chuyen de Ung budu hgc t?p 9(4), tr 281-288.
16. Van Tan. H o a r ^ Danh Tan, Nguyin Cao Cuong (2004). Cit gan hvng ung tive gan nguyin phat T^p chi y hgc Viet Nam, Tap 297, so d i e bi?l tfiang 4-2004:14-18
17 Wade TP, Cameron RB (1994) Malipiandes of the Kwr and mtrahepatic biliary tract Pradieal oncology Hist Editioi.
Appleton & Lange, pp, 258- 264
Ngdy nhan bdibdo: 12/11/2013 Ngdy phdn bien nhan xet bai bdo: 01/12/2013 Ngdy bdi bdo duac Mng: 20/02/2014
