Ultrasound Rumak-Vietnamese Full

C H N G 1 5
T cung va phan phu

Shia Salem, M.D., F.R.C.P.C.
D A N B A I
GIAI PHAU HOC VUNG CHAU BNH THNG Nhng ton thng khong tan sinh
KY THUAT SIEU AM Nhng nang chc nang
So sanh sieu am nga bung vi nga am ao Nhng nang xuat huyet
T CUNG Hoi chng di tch buong trng
Giai phau sieu am bnh thng Nhng nang canh buong trng (canh tai voi)
Nhng bat thng bam sinh Nhng nang an cua phuc mac
Nhng bat thng cua c t cung Lac noi mac t cung
U c trn (U x) Benh buong trng a nang
U m t cung (U c m) Xoan buong trng
Sarcoma c trn Phu buong trng lan rong
Lac noi mac trong c t cung Nhng khoi tan sinh
D dang ong-tnh mach Ung th buong trng
Nhng bat thng cua noi mac t cung Dau hieu Doppler cua ung th buong trng
Noi mac sau man kinh Nhng u bieu mo-mo em be mat (Suface
dch va mau t cung-am ao Epithelial-Stroma Tumors)
Tang san noi mac t cung Nhng u te bao mam
Teo noi mac t cung Nhng u mo em-cot gii tnh (Sex Cord-
Polyp noi mac t cung Stromal Tumors)
Carcinom noi mac t cung Nhng u di can
Viem noi mac t cung VOI TRNG FALLOPE
Dnh noi mac t cung Benh viem vung chau cap tnh (PID)
Nhng dung cu tranh thai trong t cung Dau hieu sieu am cua PID
Nhng bat thng cua co t cung Carcinoma
AM AO ANH GIA SIEU AM MOT U VUNG CHAU
TUI CUNG TRC TRANG-T CUNG (TUI U VUNG CHAU KHONG THUOC PHU KHOA
CUNG SAU) U vung chau sau mo
BUONG TRNG U ong tieu hoa
Giai phau sieu am bnh thng U ng nieu
Buong trng sau man kinh BENH LY VUNG CHAU THI KY HAU SAN
Nhng nang sau man kinh Sot nhau
Viem huyet khoi tnh mach buong trng
Nhng bien chng cua mo bat con
520 SIEU AM BUNG, CHAU VA NGC
Sieu am gi mot vai tro can thiet trong viec cung hay tui cung trc. Vung nay thng trong,
anh gia benh ly phu khoa. Ngay nay, ca sieu am nhng co the cha cac quai ruot. Pha sau, phuc
nga bung va nga am ao eu la nhng ky thuat a mac trai eu en tui cung am ao tao nen ngach
chng to la rat tot e anh gia cac c quan vung t cung-trc trang, hay tui cung sau. pha ben,
chau cua phu n. Sieu am mau va sieu am Doppler phuc mac tao nen cac day chang rong, la phan
pho a phat trien dan mot cach t nhien e am trai dai t mat ben cua t cung en thanh ben vung
nhan vai tro anh gia dong mau bnh thng va chau. Cac day chang tron xuat phat t sng t
benh ly. Doppler cung co the phan biet cac cau cung pha trc so vi hai tai voi trong cac day
truc mach mau vi cac cau truc khong phai la chang rong, trai dai ve pha trc ben, va i xuyen
mach mau nh cac tai voi gian, hay cac quai ruot qua hai ong ben e bam vao can mac cua moi ln.
cha ay dch. Gan ay hn, viec ng dung sieu Co t cung nam pha sau goc bang quang
am buong t cung (sonohysterography) a giup va gan chat vao goc bang quang bang day chang
anh gia chi tiet hn ve noi mac t cung, cho phep rong. Co t cung m vao trong phan tren am ao
phan biet nhng ton thng di noi mac, tai noi qua lo ngoai co t cung. Am ao la mot ong c
mac hay trong buong t cung. Sieu am cung ong si, nam ng gia va chay t co t cung en
mot vai tro quan trong trong viec hng dan cac tien nh cua bo phan sinh duc ngoai. Co t cung
thu thuat can thiep. Chup X quang cat lp ien nho vao pha tren am ao, tao nen mot vung gia
toan (CT) va hnh anh Cong hng t (MRI) co vai cac thanh am ao va be mat cua co, goi la tui
tro bo sung khi sieu am khong ket luan c va khi cung am ao. Mac du vung nay lien tuc, ngi ta
anh gia giai oan cua cac u ac tnh vung chau. chia no thanh tui cung trc, sau va hai tui cung
ben.
GIAI PHAU VUNG CHAU BNH THNG Hai tai voi chay ra hai ben t t cung, trong b
t do pha tren cua day chang rong. Moi tai voi
T cung la mot c quan co cau truc c, rong, thanh thay oi t 7 en 12cm chieu dai va chia thanh cac
day. Cau truc ben trong cua no gom mot lp c, oan trong thanh, oan eo, oan bong, va oan
hay c t cung tao nen phan ln thanh phan t pheu. oan trong thanh dai khoang 1cm, ben
cung, va mot lp nhay, goi la noi mac t cung, la trong thanh c cua t cung va la phan hep nhat
phan dnh chac vi c t cung. T cung nam gia cua tai voi. Eo, tao nen mot phan ba gia, hi rong
hai lp cua day chang rong pha ben, bang quang hn, tron, hnh ong va lien tuc vi bong, la phan
pha trc, va ai trang sigma-trc trang pha ngoan ngoeo va tao nen gan nh phan na chieu
sau. No c chia thanh hai phan chnh la than va dai tai voi. Bong ket thuc phan xa nhat, la pheu
co, bi mot oan hi hep ngang mc cua lo trong hay goi la au co tua, no co dang pheu va m vao
co t cung. ay la vung tren than t cung, pha trong khoang phuc mac ( Hnh 15-1).
tren lo vao hai tai voi. Vung than ni ma tai voi i Hai buong trng co dang hnh elip, vi truc
vao t cung c goi la sng. Mat trc cua ay dai luon theo hng thang ng. Be mat cua buong
va than t cung c bao bi phuc mac. Vung phuc trng khong c bao bi phuc mac, nhng bi mot
mac pha trc t cung la tui cung bang quang-t lp te bao duy nhat hnh tru hay hnh khoi, c
Hnh 15-1. C quan phu khoa bnh thng. S o t cung, buong trng, voi trng
va cac cau truc tng quan. Ben trai, a lay o day chang rong. (c phep cua Jocelyne
Salem).
T cung va Phan phu 521
goi la bieu mo mam, lien tuc vi phuc mac tai ron tnh mach chu di, pha di so vi tnh mach
cua buong trng. Cau truc ben trong cua buong than phai, ngc lai, tnh mach buong trng trai o
trng chia thanh phan vo ben ngoai va tuy ben trc tiep vao tnh mach than trai.1
trong. Phan vo la khung co cau truc mo ke, hay mo Dan lu bach huyet cua cac c quan vung
em, bao gom cac si li va cac te bao hnh thoi chau a dang nhng co khuynh hng theo cac
va cha nhng nang noan va hoang the. Ben di kieu co the nhan biet c. Cac mach bach huyet
bieu mo mam, mo lien ket cua vo hp lai e tao cua buong trng i kem ong mach buong trng ve
thanh vo bao si, goi la lp vo trang. Phan tuy, pha ngoai ong mach chu va cac hach bach huyet
vi the tch nho hn phan vo, bao gom mo si va quanh ong mach chu. Cac mach bach huyet cua
cac mach mau, ac biet la cac tnh mach. phu n ay va phan tren than t cung va tai voi i kem
cha sanh, buong trng nam mot cho lom tren cac mach bach huyet cua buong trng. Cac mach
vach chau hai ben goi la ho buong trng, gii han bach huyet cua phan di than t cung i ve pha
pha trc bi ong mach ron a b tac, gii han ngoai en cac hach bach huyet chau ngoai, ngc
pha sau bi t cung va ong mach chau trong va lai, cac mach bach huyet cua co t cung i theo ba
pha tren bi tnh mach chau ngoai. Cac tua cua tai hng ra ngoai en cac mach bach huyet chau
voi nam pha tren va pha ngoai so vi buong ngoai; ra sau ngoai, en hach bach huyet chau
trng. Mat trc cua buong trng bam vao mat sau trong; va ra sau, en cac hach bach huyet cung
cua day chang rong bang mot mac treo buong ben ngoai. Cac mach bach huyet cua phan tren am
trng ngan. Cc di cua buong trng bam vao t ao i ra ngoai cung vi cac nhanh cua ong mach
cung bi day chang buong trng, ngc lai, cc t cung, o vao cac hach bach huyet chau trong va
tren bam vao vach chau ben bi s trai dai ve pha ngoai, ngc lai, cac mach bach huyet cua phan
ngoai cua day chang rong, c goi la day chang gia am ao i theo cac nhanh ong mach am ao
treo buong trng (pheu-chau). Day chang treo cha gan lo mang trinh hp vi cac mach bach huyet
cac mach mau va than kinh buong trng. Nhng cua am ho va dan ve cac hach bach huyet ben
day chang nay khong chac chan, va do o buong nong.1
trng co the kha di ong, ac biet nhng phu n
mang thai. KY THUAT SIEU AM
Cung cap mau ong mach en t cung chu
yeu t ong mach t cung, la mot nhanh ln cua Hnh anh sieu am qua thanh bung chuan c
than trc ong mach chau trong. ong mach t thc hien vi bang quang cang nc tieu, e tao
cung i len doc theo b ben cua t cung trong day mot ca so am, nham quan sat cac c quan vung
chang rong va en ngang mc cua sng t cung, no chau va xem nh la mot tieu chuan tham khao e
chay ve pha ngoai e noi vi ong mach buong anh gia cac cau truc dang nang. Bang quang cang
trng. Cac ong mach t cung se thong noi vi ay ruot ra khoi vung chau va ay cac c quan
nhau qua ng gia nh cac ong mach cung vung chau ra xa thanh bung trc t 5 en 10cm.
trc va sau, la cac ong mach chay trong day Nen dung au do tan so cao nhat. Trong thc te,
chang rong, va sau o i vao c t cung1,2. am roi thng dung au do tan so 3,5 MHz cho phan ln
cac tnh mach t cung song hanh theo cac ong trng hp sieu am. Tuy nhien, nen dung au do
mach. tan so 5,0 MHz mot khi co the. Bang quang cha
ong mach buong trng xuat phat t pha nc tieu c xem nh cang ly tng khi no phu
ngoai cua ong mach chu bung, hi ve pha di so qua toan bo ay t cung. Bang quang cang qua
vi cac ong mach than. No bat cheo cac mach mc co the e ep lam bien dang cau truc giai phau
mau chau ngoai vanh chau va chay vao gia va cung co the ay cac c quan vung chau ra khoi
trong day chang treo buong trng. Sau khi phan cac vung hoi tu cua au do, lam gii han viec quan sat
nhanh vao buong trng, no tiep tuc chay ve pha chi tiet.
trong trong day chang rong e thong noi vi ong Hnh anh t cung va phan phu c quan sat
mach t cung. Cac tnh mach buong trng i ra cac mat cat doc gia lan mat cat ngang. Truc doc
khoi ron buong trng va tao nen mot am roi tnh t cung c xac nh tren mat cat doc gia, va
mach trong day chang, thong noi vi am roi tnh thng can phai tao goc hi chech e quan sat toan
mach t cung. Tnh mach buong trng phai o vao bo t cung va co t cung. Co the quan sat phan phu
bang cach quet chech t ben oi dien, mac du nhe va phan hong hai ben hi nang len tren mot
trong nhieu trng hp, co the ghi nhan c hnh cai goi. Phan hong nang cao cho phep ngi lam
anh bang cach quet trc tiep ngay tren vung phan sieu am di chuyen au do mot cach t do. T the
phu, ac biet khi bang quang cang qua mc, ay Trendelenburg ao nghch nhe co the giup ha
phan phu ra khoi vung tam iem cua au do. Can thap cac c quan vung chau. ieu quan trong la
an nhe au do e a vung can khao sat vao trong tranh at benh nhan vao t the Trendelenburg, v
vung tam iem au do. co the bo sot dch vung chau lng t.
Khi sieu am nga am ao, phai e bang Vi viec xoay nhe va be goc au do, co the
quang trong e a cac c quan vung chau vao thay c ca hnh anh cat ng doc va cat ngang.
vung hoi tu cua au do am ao. Bang quang trong Hi be goc au do ra trc se a ay cua mot t
cung em lai cam giac de chu cho benh nhan cung gap trc vao trng nhn. e quan sat co t
trong suot qua trnh sieu am, dung au do am ao cung, phai keo nhe au do ra pha ngoai, xa lo
vi tan so 5,0 en 7,5 MHz. au do c boi gel ngoai co t cung. Co the can phai be goc au do
sieu am va sau o c boc mot bao bao ve bang het mc e quan sat toan bo phan phu va tui cung.
cao su, thng la mot bao cao su tranh thai. Nen An nhe bung giup a cac cau truc phan phu sat
loai tr het cac bot kh e tranh cac anh gia. Sau au do.
o dung mot chat boi trn ben ngoai boi vao mat nh hng hnh anh luc ban au co the b
ngoai cua bao bao ve. au do c a vao trong boi roi do cac hnh anh cat doc gia c bieu lo
am ao vi benh nhan nam nga, hai au goi co 900 ngc chieu kim ong ho so vi nh hng
Hnh 15-2. nh hng trong sieu am qua nga am ao. A, Minh hoa sieu am trong am ao, cat ng doc.
B, Hnh anh sieu am t cung tng ng. C, Minh hoa sieu am trong am ao, cat theo mat phang tran. D, Hnh anh t
cung cat tng ng. R ,ben phai; L, ben trai; cephalad: pha au (A va C, c phep cua Jocelyne Salem.)
thc s cua no; ngc lai, nhng hnh cat mat la khong the sieu am cho nhng benh nhan khong
phang tran c xoay tng t hng au chan gi bang quang cang c, benh nhan beo ph,
nhng c boc lo ung khi nh hng trai phai anh gia mot t cung gap sau, trong o, ay t
(Hnh 15-2) cung co the nam ra khoi vung hoi tu cua au do,
Sieu am buong t cung oi hoi phai truyen khong xac nh u ac iem cac u phan phu. Do
nc muoi vo trung vao trong long t cung. at au do nam gan t cung va phan phu, sieu am qua
mot mo vt vo trung va lam sach co t cung bang nga am ao cho phep s dung cac au do tan so
mot dung dch sat khuan. ut mot ong thong, cao hn, tao ra o phan giai tot hn. Tuy nhien, v
thng la ong nuoi an 5F cua tre em vao trong tan so cao hn, trng quan sat b gii han, va o
buong t cung en ngang ay t cung. Nen bm la iem bat li chnh cua ky thuat nay. Cac khoi
ay nc muoi vao ong thong trc khi a vao e ln co the lap ay hay vt khoi trng nhn, gay
giam thieu anh gia do kh. Cung co the dung mot nen s nh hng kho khan, va nhng buong trng
ong thong chup t cung-voi trng co bong va can hay cac khoi nam pha tren hay ra ngoai co the
thiet cho nhng phu n co co t cung rong hay khong c nhn thay. Sieu am qua nga am ao
khong kn e tranh r ngc nc muoi vao trong phan biet tot hn cac khoi phan phu vi cac quai
am ao. Nen at bong cang sat vi lo trong cang ruot va cung cap chi tiet hn nhieu nhng ac tnh
tot va bm vao nc muoi, khong c bm kh. ben trong mot khoi vung chau do o phan giai
Sau o lay mo vt ra va a au do am ao c cai thien. Nh vay, hai ky thuat bo sung lan
vao ben trong am ao. Xac nh v tr ong thong nhau.
trong long t cung va sau o bm t t nc muoi Mot vai nghien cu so sanh hai ky thuat trong
vo trung qua ong thong di s kiem soat lien tuc nhieu benh ly vung chau a cho thay rang sieu am
cua sieu am. T cung c sieu am mot cach he qua nga am ao cung cap chi tiet giai phau va chat
thong cac mat cat ng doc va mat phang tran lng hnh anh tot hn.4-8 ieu nay khong co g
e mo ta toan bo long t cung. Khong khao sat ngac nhien v a s dung cac au do tan so cao
nhng phu n co benh ly viem cung chau cap tnh. hn. Ch co mot vai nghien cu so sanh cac dau
Phai dung khang sinh d phong nhng phu n co hieu sieu am vi ket qua phau thuat. Andolf va
benh ly viem cung chau man tnh va cac phu n Jorgensen nhan thay khong co s khac biet ang
co benh s sa van hai la hoac cac roi loan ve tim ke ve ket qua chan oan gia hai ky thuat mac du
khac.3 chat lng hnh anh cua sieu am qua nga am ao
tot hn.9 DiSantis va cs. ch dung sieu am qua nga
Sieu am qua nga bung so vi sieu am qua am ao trong 72 gi phau thuat vung chau chon
nga am ao loc, a phat hien ra 16 trong 21 (76%) buong trng
Sieu am qua nga bung va qua nga am ao la bnh thng ve mat mo hoc phu n tien man kinh
nhng ky thuat bo sung nhau; ca hai c dung va ch co 12 trong 59 (20%) phu n sau khi man
rong rai trong viec anh gia vung chau phu n. kinh. Ch phat hien c cac khoi phan phu 13
Sieu am nga bung quan sat toan bo vung chau va trong 22 (59%) phu n tien man kinh va 6 trong 11
cho ta mot cai nhn tong the. Gii han chnh cua no (54%) phu n sau khi man kinh.10
Phan ln cac phong th nghiem, bao gom
cua ca rieng toi, dung sieu am qua nga bung khi
U IEM CUA SIEU AM NGA AM AO bat au khao sat vung chau, sieu am qua nga am
ao e anh gia chi tiet hn neu can. Neu benh
S dung au do tan so cao hn cho o phan giai tot
hn
Khao sat benh nhan khong the gi bang quang cang CH NH CUA SIEU AM NGA AM AO
Khao sat nhng benh nhan beo ph
anh gia nhng t cung gap sau Nhng dau hieu qua nga bung khong chac chan
Phan biet ro hn gia cac khoi phan phu va nhng Xac nh ro ac iem cua mot ton thng
quai ruot Benh s gia nh ve ung th buong trng ro ret
Quan sat chi tiet hn cac ac tnh ben trong cua mot Nghi ng bat thng noi mac t cung
khoi vung chau anh gia nhng t cung nga sau hay gap sau
nhan en vi mot bang quang trong, co the khi Tng t, cung nen lam sieu am qua nga am ao
au dung sieu am qua nga am ao, nhng cung nhng phu n nghi ng co cac benh ly noi mac t
nen lam sieu am qua nga bung, ngay ca khi bang cung . e sieu am theo doi, ch can ky thuat chan
quang trong, e loai tr mot u ln vung chau. oan nao hieu qua hn.
Nhieu phu n se yeu cau dung ca hai cach. Tuy
nhien, neu sieu am qua nga bung hoan toan bnh T CUNG
thng hay phat hien thay mot bat thng c
xac nh ro, thng khong can lam g them. Nen Giai phau sieu am bnh thng
lam sieu am qua nga am ao neu nhng dau hieu T cung nam thc s trong vung chau, gia bang
qua nga bung khong chac chan hay khong co sc quang pha trc va ai trang sigma-trc trang pha
thuyet phuc hoac muon the hien ton thng ro hn. sau (Hnh 15-3) .T the t cung co the thay oi va
cac benh nhan co nguy c benh ly cao, nh mot nhng thay oi tuy theo mc o cang len khac
benh s gia nh ro rang ve ung th buong trng, nhau cua bang quang va trc trang. Co t cung co
cung nen lam sieu am qua nga am ao, ngay ca nh ng gia, nhng than t cung th kha di
neu sieu am qua nga bung co ve bnh thng. ong va co the nam chech ve ca hai ben ng
gia. o gap cua t cung c xac nh khi so truc
cua than vi truc cua co t cung, ngc lai, o nga
c xac nh khi so truc cua co t cung vi truc
cua am ao. T cung thng gap trc va nga
trc, nhng cung co the t the trung gian hay
hi nga sau tren sieu am nga bung do bang quang
cang ay ra pha sau. T cung cung co the nga sau
khi than t cung nghieng ra sau (so vi co t cung)
hay gap sau khi toan bo t cung nghieng han ra
pha sau (so vi am ao) (Hnh 15-4). Thng kho
anh gia ay cua t cung nga sau hay gap sau
bang sieu am nga bung. Khi phan t cung nay xa
au do, chung co the co phan am kem va trong
giong nh mot u x. Sieu am nga am ao a chng
minh la co the anh gia rat tot t cung gap trc
Hnh 15-3. T cung bnh thng, co (C) va am ao hay nga trc, v au do gan sat vi vung ay t
(V). cung pha sau.8
Hnh 15-4. T cung nga sau va gap sau. A, Sieu cat ng doc qua nga thanh bung cho thay t cung nga sau. B, Cat doc
qua sieu am nga am ao cho thay t cung gap sau. Lu y noi mac (mui ten). U, t cung; C, co; B, bang quang
Kch thc va hnh dang cua t cung bnh cau truc ong dang, ong nhat, phan am kem en
thng thay oi trong suot cuoc i va lien quan trung bnh. Lp trong cua c t cung mong, dnh
en tuoi, tnh trang noi tiet va tnh tranh sanh n. chat, va tng oi t mach mau.17,18 Lp trong nay,
T cung tre em hay trc tuoi day th dai t 2,0 la phan co phan am kem va bao quanh lp noi mac
en 3,3 cm, vi co t cung chiem hai phan ba toan co phan am va phai, cung c xem nh vanh
bo chieu dai, va ng knh trc sau t 0,5 en di noi mac. Lp ngoai mong co phan am hi
1,0 cm.11 T cung trc tuoi day th co dang ong kem hn lp gia va c tach khoi lp gia bang
hay dang qua le ngc, vi ng knh trc sau cac mach mau cung.
cua co ln hn ng knh trc sau cua ay t Cac ong mach cung nam gia lp ngoai va
cung.12 ngay giai oan s sinh, do s kch thch lp gia cua c t cung va phan nhanh thanh cac
cua noi tiet to me con lai, t cung s sinh co chieu ong mach tia, t o chay vao lp gia en ranh
dai khoang 0,6 en 0,9 cm va ng knh trc sau gii vi lp trong. ong mach tia sau o phan
t 0,7 en 0,8 cm, ln hn t cung trc tuoi day nhanh thanh cac ong mach xoan i vao lp noi
th.13 Cung do s kch thch cua noi tiet me con lai, mac t cung. Cac tnh mach t cung ln hn cac
ta co the thay mot ng noi mac co phan am ong mach cung i kem, va thng trong nh
gan nh tat ca t cung s sinh, va cung co the co nhng vung phan am trong nho, khu tru tren ca
mot t dch long t cung (Hnh 15-5).14 sieu am nga bung va nga am ao. Ta co the xac
Sau 7 tuoi, t cung dan dan tang kch thc cho nh chung bang khao sat Doppler (Hnh 15-6). Co
en tuoi day th. Tai thi iem nay, co s tang ro the thay voi hoa cac ong mach cung phu n sau
ret hn ve kch thc, vi phan than phat trien man kinh do x hoa Monkeberg.20,21 Tren sieu am,
manh hn cho en khi cuoi cung at c dang hien tng voi hoa nh vay trong nh nhng vung
qua le cua t cung ngi ln, vi ng knh va co phan am dang vach co bong lng ngoai bien;
chieu dai phan than khoang gap oi phan co t ta nen phan biet chung vi voi hoa trong u x t
cung.12 T cung sau tuoi day th, hay t cung cung (Hnh 15-7). ay la mot qua trnh dien tien
ngi ln bnh thng thay oi ang ke ve mat theo tuoi bnh thng; co the dien dien nhanh hn
kch thc. Kch thc ln nhat cua t cung cha nhng benh nhan tieu ng.
sanh khoang 8 cm chieu dai, 5 cm chieu rong va 4 nhng phu n bnh thng, ta co the thay
cm ng knh trc sau. Sanh nhieu lan se lam cac o nho tang phan am lp trong cua c t cung
tang kch thc bnh thng len hn 1cm moi (Hnh 15-8). Nhng o nay o ch mot vai mm, co
chieu o.15,16 Sau khi man kinh, t cung teo lai, vi the mot hay nhieu o va thng khong co bong
viec giam kch thc nhanh nhat xay ra 10 nam lng. Ngi ta ngh chung bieu hien cho tnh trang
au sau man kinh. nhng benh nhan tren 65 tuoi, voi hoa do loan dng lien quan en cac can thiep
t cung co chieu dai trong khoang 3,5 en 6,5cm trc o nh nong va nao thai hay sinh thiet trong
va ng knh trc sau t 1,2 en 1,8cm.16 co t cung.22 Chung khong quan trong ve mat lam
C t cung bnh thng co ba lp ma ta co the sang.
phan biet tren sieu am. Lp gia day nhat va co Co the anh gia s ti mau t cung bang
Hnh 15-5. T cung s sinh bnh thng. Hnh cat ng doc. Lu y hnh thai trai le
ngc vi ng knh trc sau va be dai cua co (C) ln hn cua than. A, Noi mac (mui ten)
mong va bnh thng. B, Co mot t dch ben trong kenh noi mac (mui ten). B, bang quang
sieu am Doppler duplex hoac sieu am Doppler nang day len trong suot chu ky kinh nguyet va b
mau cac ong mach t cung. cac phu n bnh bong ra moi ky hanh kinh. Lp nen gi nguyen
thng, dang song Doppler thng bieu hien kieu ven trong suot chu ky kinh va cha cac ong mach
van toc cao, tr khang cao. xoan, la cac ong mach keo dai ra e nuoi cho lp
Khoang noi mac bnh thng hien len nh nong khi lp nay day len. Giai oan tang sinh cua
mot ng mong co phan am do s phan chieu t chu ky kinh, trc khi rung trng, chu anh hng
mat tiep giap gia hai mat oi dien cua noi mac t cua estrogen, ngc lai, progesteron chu yeu chu
cung.23 Hnh anh sieu am cua noi mac t cung thay trach nhiem duy tr noi mac giai oan che tiet
oi suot chu ky kinh nguyet (Hnh 15-9, A, B va C) sau khi rung trng. giai oan hanh kinh, noi
va co tng quan ve mo hoc.17,24,25 Noi mac gom mac gom mot ng mong, co phan am khong lien
lp chc nang nong va lp nen sau. Lp chc tuc. Suot giai oan tang sinh, noi mac t cung day
Hnh 15-6. Tnh mach t cung. A, Sieu am qua nga am ao, cat doc t cung cho thay nhieu o phan am
trong ngoai bien; lu y dch bang bao quanh t cung. B, Khang nh bang Doppler mau. Noi mac t cung (e),
lp trong cua c t cung co phan am giam (i). Lp ngoai cua c t cung ngan cach vi lp trung gian bi cac
tnh mach cung.
Hnh 15-8. ong voi do loan dng lp trong cua

c t cung. Sieu am qua nga am ao cho thay nhng o tang
phan am (mui ten) kem bong lng nam trong lp trong co phan
Hnh 15-7. ong voi ong mach cung. Hnh sieu am am kem cua c t cung, boc quanh noi mac t cung (e).
cat ng doc cho thay nhieu o nho dang thang, co phan am
tang nam ngoai bien (mui ten cong).
Hnh 15-9. Nhng bien oi cua noi mac. Sieu am qua nga am ao. A, Noi mac tang sinh giai oan
sm, mong, bnh thng. B, Noi mac tang sinh giai oan tre, bnh thng co hnh thai ba lp. ng phan am
tang trung tam do cac be mat noi mac oi dien nhau, bao quanh la lp day hn co phan am giam, ngoai na
la lp nen co phan am tang. C, Giai oan che tiet, noi mac day, tang phan am. D, Sau man kinh, noi mac
bnh thng mong. E, Noi mac sau man kinh, tang sinh, day len, gii han ro, phan am tang. F, Sieu am
buong t cung cho thay noi mac day vi nhieu polyp nho. G, Noi mac day, nang hoa, do tang sinh benh
nhan co s dung tamoxifen. H, Polyp tron, gii han ro, tang phan am nhe so vi noi mac bao quanh trong
giai oan che tiet. I, Noi mac day, nang hoa do polyp ln benh nhan s dung tamoxifen.
at t 4 en 8 mm. Tot nhat nen o noi mac tren oan che tiet lien quan en viec gia tang chat nhay
ng cat doc gia t cung va nen o gom ca phan va glycogen trong cac tuyen, cung nh gia tang so
noi mac thanh trc va sau. ieu quan trong la lng giao dien do s uon khuc cua cac ong mach
khong c tnh luon lp trong phan am kem, xoan. Ta co the thay hien tng tang am pha
mong cua c t cung trong phan o nay. Quanh lp sau lp noi mac che tiet, nhng hnh anh nay
trung tam co phan am tang, co the thay mot vung khong ac hieu, v du khong thng gap, ta cung
phan am tng oi kem, bieu hien cho lp chc co the thay tang am sau lp noi mac giai oan tang
nang. Trong giai oan tang sinh sm, vung phan sinh.25
am kem nay mong, nhng no se day len va co gii Sau khi man kinh, noi mac teo lai v khong
han ro hn giai oan tang sinh tre, co le do phu. con chu anh hng cua noi tiet to. Tren sieu am,
Hnh anh phan am kem cua noi mac giai oan tang ta thay noi mac la mot ng mong, co phan am,
sinh lien quan en cau truc mo hoc tng oi ong day khong qua 8 mm (Hnh 15-9, D).
nhat, do s sap xep th t cua cac thanh phan
tuyen. Sau khi rung trng, khi noi mac tien trien Nhng bat thng bam sinh
sang giai oan che tiet, lp chc nang cua noi Bat thng bam sinh t cung xay ra trong khoang
mac thay oi t phan am kem sang phan am 0,5% phu n , va i kem vi tang t le say thai t
manh.24,25 Noi mac giai oan nay day 7 en 14 nhien cung cac bien chng san khoa khac.26 oan
mm. Cau truc phan am manh cua noi mac giai uoi hp nhat cua hai ong Muller (can trung than)
tao nen t cung, co t cung, va phan tren am ao,
trong luc o, oan au khong dnh nhau va hnh
NOI MAC T CUNG CHA MAN KINH thanh hai voi trng. S hp nhat xay ra ve pha
au, va vach gia t thanh trong cua hai ong
Hanh kinh ng mong, t oan, co phan am Muller se hap thu, e lai mot buong t cung duy
Tang sinh ng phan am kem, nhat.2
day 4 en 8mm
D dang t cung (Hnh 15-10) co the do:
Che tiet ng phan am manh,
day 7 en 14mm
S phat trien cac ong Muller b dng lai.
Khong co s hp nhat cua cac ong Muller; hay
Khong co s hap thu vach gia.
Hnh 15-10. Bat thng bam sinh cua t cung. S o cac loai thng gap. (c phep cua Jocelyne Salem).
S phat trien hai ong Muller b dng lai co phan am cua noi mac t cung hai sng hay t
the xay ra mot ben hay hai ben. S phat trien b cung hai ngan. Sieu am cung co the xem bao quat
dng lai hai ben cc hiem va gay nen khong co ng b ben ngoai t cung. t cung kep va t
t cung hay bat san t cung bam sinh. S phat cung hai sng, khoang noi mac c tach xa han
trien dng lai mot ben gay ra t cung mot sng ra, va co mot cho lom sau ng b ben ngoai
mot co (mot sng t cung va mot co t cung). S cua ay t cung (Hnh 15-11, A). Ngc lai, t
giam san cua mot ong Muller co the gay ra mot cung hai ngan co b ngoai tng oi bnh thng,
sng t cung cha hoan thien. Phan ln cac sng t va hai khoang noi mac gan nhau, va c tach ra
cung cha hoan thien khong thong nhau va noi vi bi mot vach si mong (Hnh 15-11, B). Vach co
sng oi dien bang mot dai si. Neu noi mac t mau nuoi kem va neu co c t cung th co rat t.30
cung mot sng t cung cha hoan thien khong co Sieu am ket hp vi chup buong t cung-voi trng
chc nang, se khong bieu hien cac trieu chng lam co o chnh xac cao khi phan biet gia t cung hai
sang, nhng neu noi mac t cung co chc nang, co ngan va t cung hai sng.31 Viec phan biet hai
the xay ra s mau kinh sng cha hoan thien. trng hp nay la quan trong, v co the ieu tr t
Khong co s hp nhat cua cac ong Muller cung hai ngan bang cach cat i vach si qua soi
co the la toan phan, gay ra t cung kep ( hai am buong t cung benh nhan ngoai tru, nhng v t
ao, hai co t cung, hai t cung); hay mot phan, cung hai sng co hai sng t cung rieng biet, moi
gay ra hoac t cung hai co hai sng (mot am ao, sng co ay u thanh phan c va noi mac, viec
hai co t cung, hai sng t cung), hoac t cung chnh sa oi hoi phai phau thuat bung.
mot co hai sng (mot am ao, mot co t cung, hai Sieu am kho chan oan phan biet t cung mot
sng t cung). T cung dang cung la mot bat sng va t cung bnh thng. Co the nghi ng khi
thng ve s hp nhat mc o nhe nhat, lam cho t cung dng nh nho va nam ve pha ben. dch
ay t cung lom mot phan vi mot khoang noi mac sng khong hoan thien ben oi dien co the thay
tng oi bnh thng, va c xem nh mot dang va chan oan sai la mot khoi t cung hay phan
rat nhe cua t cung hai sng hay mot dang bien the phu. Neu khong thay phc hp phan am cua noi
bnh thng cua t cung. mac trung tam tai mot sng, ta cung co the lam
Khong hap thu vach gia gay ra mot t cung t cung hai sng vi mot khoi t cung hay phan
hai ngan hay t cung co vach ngan ban phan, phu. Trong nhieu trng hp, t cung hai sng au
lan lt phu thuoc vao s khong hap thu toan phan tien c chan oan ngau nhien giai oan au
hay ban phan. ieu nay tao ra s nhan oi toan cua thai ky, khi tui thai co mot sng, va co phan
phan hay ban phan cua buong t cung, khong kem ng mang rung sng ben kia (Hnh 15-11, C).
theo nhan oi cac sng t cung, va ay la bat MRI co o chnh xac cao khi mo ta ro cac bat
thng t cung thng gap nhat. T cung hai ngan thng t cung. Tuy nhien, v gia thanh cua MRI
hay t cung co vach ngan ban phan co the phan tng oi cao, nen thng danh e phat hien cac
biet vi t cung hai sng bang cach xem ng b bat thng phc tap hn.
ben ngoai t cung. Cac bat thng t cung cung co the thay
D dang t cung rat thng kem theo cac bat nhng benh nhan co t cung tiep xuc vi
thng than bam sinh, ac biet la khong co than diethylstilbestrol. Diethylstilbestrol dung trong
va than lac cho.27 Bat thng t cung kem vi suot tam ca nguyet au i qua nhau va co anh
khong co than thng gap nhat la t cung hai co hng trc tiep len he thong Muller cua thai nhi.
hai sng vi mot vach ngan mot phan am ao,
trong o mot ben khong co lo thoat cho mau kinh,
gay ra mau t cung am ao mot ben. tat ca PHAN LOAI LEIOMYOMA (U C TRN)
benh nhan co d dang t cung, nen sieu am anh
gia hai than. Cung vay, tren cac phu n khong co Trong thanh Nam trong c t cung
than hay than lac cho, nen sieu am t cung tm d Di niem mac Nho vao trong buong t cung
dang.Thng gap cac bat thng cung mot ben. Di thanh mac Nho ra t be mat phuc mac
Phan ln cac bat thng t cung co the phat
hien c bang sieu am.29 Co the thay hai ng
Hnh 15-11. Bat thng t cung. A, Sieu am qua

nga am ao, cat ng ngang qua ay mot t cung hai
sng cho thay hai noi mac (mui ten) cach nhau xa bi
mo c t cung. B, Tng t cat qua ay mot t cung hai
ngan cho thay hai noi mac (mui ten) ch cach nhau bi
chut mo c t cung. Cac noi mac dnh nhau phan thap
cua t cung. C, Sieu am qua nga thanh bung, cat ngang
qua ay mot t cung hai sng cho thay tui thai (G)
sng ben trai va phan ng mang rung (mui ten) sng
ben phai.
Sieu am co the mo ta ro s giam lan toa kch thc Nhng u x phu thuoc estrogen va co the
t cung va mot buong t cung khong eu dang tang kch thc trong suot cac chu ky khong phong
T.33,34 noan la do cua s kch thch estrogen khong kiem
soat,36 va trong suot thai ky, mac du khoang phan
Cac bat thng cua c t cung na so u x bieu hien thay oi t ang ke trong
Leiomyoma (U x). Leiomyoma la u t cung suot thai ky.37 Cac u x ln khong gay tr ngai cho
thng gap nhat. Chung xay ra khoang 20% en thai ky hay cuoc sanh bnh thng qua nga am ao,
30% phu n tuoi tren 30,35 va chung thng gap tr khi chung nam phan t cung pha di hay
nhieu hn phu n da en. Chung thng co nhieu co t cung. Hiem khi chung phat trien phu n sau
u va la nguyen nhan lam ln mot t cung khong man kinh, va hau het on nh hay giam kch thc
co thai thng gap nhat. Mac du thng khong co sau khi man kinh. Tuy nhien, chung co the tang
trieu chng, phu n co u x cung co the au va kch thc cac benh nhan sau man kinh co ieu
xuat huyet t cung. Co the phan loai u x thanh u tr noi tiet thay the. Tamoxifen cung c bao cao
x trong thanh t cung, gii han bi c t cung; u la lam cho u x phat trien.38 Viec tang kch thc
x di niem mac, nho vao buong t cung va lam nhanh, ac biet nhng benh nhan sau man kinh,
bien dang noi mac; hay u x di thanh mac, nho nen ngh nhieu hn en kha nang u x bien oi
ra t be mat thanh mac cua t cung. thanh sarcomA.2
Cac u x trong thanh la thng gap nhat. Cac u Ve mat benh hoc, u x bao gom cac te bao c
x di niem mac tuy t gap hn lai thng gay ra trn, hnh thoi, sap xep thanh cac dang giong vong
trieu chng nhat. Nhng u x di thanh mac co xoan oc, c phan cach bi so lng mo si lien
the co cuong va bieu hien nh mot khoi phan ket khac nhau. C t cung bao quanh co the b e
phu. Chung cung co the nho ra gia cac la cua day ep tao vo bao gia. Khi u x to ra, chung co the phat
chang rong, ni chung c xem nh la thuoc ben trien vt qua kha nang cung cap mau nuoi chung,
trong day chang. Cac u x co t cung chiem gay ra thieu mau cuc bo va thoai hoa nang.
khoang 8% tat ca u x. Tren sieu am, u x co hnh dang thay oi
(Hnh 15-12). T cung co the ln ra, vi ng thng gap, gom cac thanh phan khac nhau cua
vien ben ngoai co dang hnh cau va cac cau truc cac te bao m trng thanh, c trn hay mo si. Ve
phan am khong ong nhat, tao nen do cac u x mat mo hoc, nhng u nay bao gom nhng u m
nho, lan toa. Nhng u x khu tru phan ln thng thuan tuy, nhng u c trn-m (lipoleiomyoma), va
co cau truc phan am kem hay cau truc phan am nhng u c-m-si. Ve mat sieu am, dau hieu mot
khong ong nhat. Chung thng lam bien dang khoi phan am manh, co giam am pha sau, trong
ng b ngoai t cung. Mot dau hieu kn ao e c t cung thc s la hnh anh e chan oan tnh
chan oan la s khong eu t nhat ng b trang nay (Hnh 15-13).45 Doppler mau cho thay
ngoai t cung tai be mat tiep xuc gia t cung va hoan toan khong co dong mau ben trong khoi
bang quang.39 Nhieu u x bieu hien cac vung giam nay.46 ieu quan trong la xac nh ton thng
am hay co bong lng, ma khong co cac khoi tach thuoc t cung e khong lam lan no vi u b buong
biet, lam ta khong the anh gia kch c u. Ngi ta trng cha m,47 co hnh anh tng t va thng
ngh giam am la do s x hoa ac trong u. Gan gap hn. V u m t cung thng khong co trieu
ay, Kliewer va cs. a cho la bong lng pha sau t chng, chung khong can phai c phau thuat.
ben trong thanh phan cua u x (khong phai t cac o Leiomyosarcoma (Sarcoma c trn). Leio-
tang phan am) bat nguon t vung chuyen tiep gia myosarcoma hiem gap, chiem 1,3% u ac tnh t
cac mo ke can. Ve mat mo hoc, cac vung chuyen cung, va co the xuat phat t mot u x t cung co
tiep bao gom cac b cua u vi c t cung bnh trc o. Thng benh nhan khong co trieu chng,
thng ke can, cac b gia mo si va c trn, va mac du co the co xuat huyet t t cung. Hiem khi
cac b cua cac vong xoan hay cac bo c.40 Voi tnh trang nay c chan oan trc mo. Ve mat
hoa co the xay ra cac phu n ln tuoi hn, sieu am, hnh anh tng t vi hnh anh u x t
thng trong nh mot o tang phan am, co bong cung phat trien nhanh hay thoai hoa, tr khi co dau
lng hay nh mot ng vien cong tang phan am, hieu xam lan tai cho hay di can xa (Hnh 15-14)
co the gia hnh anh ng b cua au thai nhi.41 Lac noi mac t cung. Lac noi mac t cung la
Thoai hoa va hoai t tao nen nhng vung co phan mot tnh trang vi ac iem benh hoc la s co mat
am giam hay cac khoang dang nang ben trong u x. cua cac tuyen va mo em cua noi mac ben trong
Hien tng nay co khuynh hng xay ra thng c t cung. No thng tap trung nhieu hn thanh
hn trong suot thai ky, anh hng en khoang 7% sau.35 Cac tuyen cua noi mac t cung xuat phat t
en 8% benh nhan mang thai co u x, co the bieu lp nen va ac trng khang lai s kch thch noi tiet
hien au vung nay. Ngi ta cung a mo ta loai to. Lac noi mac t cung co the xay ra dang lan
u x khong lo vi nhieu khoang dang nang do phu toa va dang not. Dang lan toa thng gap hn bao
ne.42 gom o lac noi mac rai rac khap ni trong c t
U x di niem mac co the e ep noi mac, gay cung, trong khi dang not gom cac not co gii han
bien dang long t cung. Sieu am qua nga am ao goi la u c tuyen. Bieu hien lam sang thng
cho phep phan biet ro hn gia mot ton thng khong ac hieu, bao gom au vung chau, thong
di niem mac va trong thanh t cung, va moi lien kinh va rong kinh.
quan cua no vi khoang noi mac.43 Trong mot vai Tren sieu am ta kho chan oan benh. Khi
trng hp, co the can thiet lam sieu am buong t dung sieu am nga bung, co the ngh en chan oan
cung e phan biet u x di niem mac vi mot ton nay neu t cung ln lan toa vi b bnh thng,
thng noi mac t cung. Sieu am nga am ao co cau truc noi mac t cung va cau truc c t cung
the phat hien nhng u x rat nho va co the chan bnh thng. Ngi ta cung mo ta hnh anh day c
oan nhng u x di thanh mac co cuong, ln, t cung thanh sau, vi vung nay hi co phan am
thuoc t cung, ma co the lam vi cac khoi phan trong hn c t cung bnh thng. Cac bao cao gan
phu. Tuy nhien, co the bo sot nhng u x di ay a cho rang sieu am nga am ao giup chan
thanh mac hay co cuong neu ch dung duy nhat oan tnh trang nay chnh xac hn (Hnh 15-15).50,51
sieu am nga am ao, do trng nhn b gii han.44 Ngi ta cung a mo ta nhng vung phan am
Nhng u x ay mot t cung gap sau c thay kem khong ong nhat ben trong c t cung, vi
ro hn bang au do am ao. cac gii han khong ro rang. Cung co the co nhng
Cac lipoma t cung (U c trn- m). Cac nang nho trong c t cung cac vung khong
lipoma t cung la s tan sinh lanh tnh, khong ong nhat nay, va a bieu hien ve mat mo hoc s
hien dien cua cac tuyen gian trong mo noi mac lac khong ro va cha cac cho khuyet phan am trong.52
cho.51 Lac noi mac t cung la nguyen nhan thng Tuy nhien, luon kho phan biet chung vi u c trn,
gap nhat cua cac nang c t cung, mac du cac nang va hai benh ly nay cung thng xay ra cung nhau.
trong c t cung cung co the co nguon goc bam MRI co o chnh xac cao trong viec mo ta lac
sinh hay co the thay trong cac u c trn ang thoai noi mac t cung, bieu hien la cac vung gii han
hoa nang. Bang sieu am nga am ao, ta co the khong ro, giam cng o tn hieu ben trong c t
thay nhng adenomyoma khu tru la cac vung co cung hay day khu tru hoac lan toa vung chuyen
gii han khong ong nhat trong c t cung, co b tiep tren cac hnh anh thien T2.53-55
Hnh 15-12. Xem chu thch trang oi dien

Hnh 15-12, tiep theo. Cac dang khac nhau cua u x t cung. A, D, E, F, H: Cac hnh sieu
am nga bung. B, C, G: Cac hnh sieu am nga am ao. A. T cung ln vi b a cung va cau truc
khong ong nhat. B. U x phan am kem khu tru (mui ten cong). C . S giam am ro ret do u x (c
anh dau ben ngoai). D. U x co voi hoa vi ng voi hoa cong (mui ten) gia anh au thai nhi. B,
Bang quang. E. U x co thoai hoa nang (mui ten) trong thai ky. Benh nhan bieu hien au va s au
tai vung u x thoai hoa. F. Thai nhi. A , dch oi. F. U x khong lo vi nhieu vung dang nang ln. Suot
thi ky, u x ln nay tang ro ret kch thc va cac vung dang nang (C). Hau san, cho thay kha nang
la sarcoma c trn. G, U x di niem mac phan am kem. (F) Noi mac t cung b bien dang va ay
lech (E). H. Hnh cat ngang cho thay u x di thanh mac co cuong (F) hien dien nh mot khoi ac
phan phu trai. Chu y s lien he (mui ten) vi t cung (UT). B, bang quang.
Hnh 15-14. Leiomyosarcoma. Sieu am cat ngang qua

Hnh 15-13. Lipoleiomyoma. Hnh cat doc gia tren nga
nga bung cho thay t cung ln, b a cung vi cau truc phan
bung cho thay khoi phan am tang (mui ten cong) vi giam
am khong ong nhat lan toa.
thau phan sau ro ret trong c t cung. Mui ten, noi mac t
cung.
D dang ong-tnh mach (AVM = arterio- cac nang buong trng nhieu thuy, cac quai ruot
venous malformations) (Hnh 15-16) bao gom cha ay dch, va dch tai voi. Doppler mau giup
mot am roi mach mau cac ong va tnh mach chan oan, bieu hien dong mau doi dao ben
khong co mot mang li mao mach gia. Chung trong cac cau truc phan am trong. Co mot dang
la nhng ton thng hiem gap, thng lien quan kham mau sac s ma trong ro hn bat thng tren
en c t cung va oi khi lien quan en noi mac t thang xam. Doppler pho cho thay dong ong mach
cung. Mac du chung co the bam sinh, phan ln cac tr khang thap, van toc cao cung vi dong tnh
trng hp xay ra lai do chan thng vung chau, mach van toc cao ma ta thng khong the phan
phau thuat va tan sinh nguyen bao nuoi cua thai. biet vi tn hieu ong mach.58
Cac benh nhan, ien hnh la phu n tre tuoi sinh ieu tr va chan oan xac nh gom chup
san co bang huyet vi mat mau giam hemoglobin. quang ong mach va lieu phap lam nghen mach.
Chan oan rat quan trong v viec nong va nao co
the dan en xuat huyet tram trong. Bat thng cua noi mac t cung
Tren sieu am, cac d dang ong-tnh mach t Do o phan giai c cai thien, sieu am nga am
cung co the khong ac hieu, vi nhng bieu hien ao co the ghi hnh va mo ta tot hn nhng bat
nho. Ta co the thay cac cau truc phan am trong, thng kn ao trong noi mac t cung va xac nh
ngoan ngoeo vung chau va co the lam lan vi ro rang ranh gii c t cung-noi mac t cung.59
Hnh 15-15. Lac noi mac t cung. A. Hnh sieu am nga am ao cho thay nang nho gii han ro (mui ten
cong) ben trong mot vung phan am kem khong ong nhat vi cac gii han khong ro rang (mui ten) phan c
ay t cung. B. Hnh sieu am nga am ao benh nhan khac cho thay mot nang gii han ro lp trong c t
cung. E. Noi mac t cung.
Hnh 15-16. D dang ong-tnh mach t cung. A. Sieu am nga am ao vi lat cat ngang bieu hien mot
vung khong ong nhat ve cau truc ay t cung. B. Hnh anh Doppler mau cho thay mot dang kham mau sac
s vi cac hnh anh ao ngc dong ro rang va cac vung mau aliasing (Trch t Huang M, Muradali D, Thurston
WA va cs. Uterine arteriovenous malformations (AVMs): ultrasound and Doppler features with MRI
correlations. Radiology 1997).
Hieu biet ve hnh anh sieu am bnh thng cua noi mac nao co noi mac t cung o di 5 mm.
mac t cung cho phep phat hien sm cac tnh trang Nhng nghien cu sau hn a anh gia noi
benh ly noi mac, ma bieu hien la day noi mac vi mac t cung cac benh nhan sau khi man kinh
b khong eu, gii han ro hay khong ro (xem khong co trieu chng, va ho nhan thay la mot noi
bang). Nhieu benh ly noi mac t cung nh tang mac t cung di 9 mm co the c xem la bnh
san, cac polyp va carcinoma, co the gay xuat thng. Phan ln cac bao cao bao gom mot nhom
huyet bat thng ac biet benh nhan sau man nhieu loai benh nhan, trong o co mot so ang
kinh. Tat ca cac trng hp nay co the co cung ieu tr hormone thay the va mot so th khong.
cac hnh anh sieu am . Hien tai, nhieu benh nhan sau khi man kinh ang
Noi mac t cung sau man kinh. Mot vai ieu tr noi tiet thay the, do lieu phap thay the
nghien cu a cho thay rang nhng benh nhan estrogen lam giam nguy c loang xng va lam
xuat huyet sau khi man kinh, ma a co sinh thiet nhe bt cac trieu chng man kinh. Tuy nhien, lieu
noi mac, so o noi mac t cung di 5mm co the phap thay the estrogen khong oi khang se kem
c xem la bnh thng.60-65 Xuat huyet cac theo vi nguy c cao tang san noi mac t cung va
benh nhan nay thng do noi mac teo. Trong mot carcinoma. Do o, estrogen lieu phap thng c
nghien cu ln gan ay tren 1168 phu n co xuat ket hp vi progesteron, theo kieu phoi hp lien
huyet sau khi man kinh, trong o tm thay 114 ca tuc hay dung tiep noi nhau. Nhng benh nhan ieu
ung th noi mac, khong co trng hp ung th noi tr noi tiet theo kieu dung tiep noi nhau co s thay
oi hnh anh noi mac t cung tren sieu am, tng
t nh noi mac t cung trc khi man kinh. Neu
Nhng nguyen nhan day noi mac t cung
xuat huyet khong theo chu ky xay ra, ta phai xem
xet en kha nang co tang san noi mac t cung, co
Thai trong t cung giai oan sm.
polyp, va khoi ac tnh. nhng benh nhan nay,
Xay thai khong tron
Thai ngoai t cung ieu quan trong la lam sieu am ca au va cuoi
Sot nhau chu ky noi tiet khi noi mac t cung mong nhat.
Benh ly dng mac Mot noi mac t cung day hn 4mm phu n
Viem noi mac t cung sau man kinh co xuat huyet, 8mm phu n sau
Dnh man kinh khong co trieu chng, oi hoi ta phai
Tang san sinh thiet noi mac t cung. Tuy nhien, neu benh
Cac polyp
nhan ang trong che o tr lieu noi tiet tiep noi
Carcinoma
nhau, ta phai lam sieu am vao au va cuoi chu ky
ieu tr (xem bang di)
Hnh 15-18. mau am ao benh nhan tre vi

mang trinh khong co lo thung. Hnh cat doc gia bung
cho thay am ao cang, cha ay chat co phan am, e ep vao
Hnh 15-17. Lng dch t trong kenh noi mac bang quang (b) pha trc.
ngi sau man kinh. Hnh sieu am qua nga am ao.
Mot lng nho dch ben trong kenh noi mac, c mc dch-dch.
phat hien bang sieu am nga am ao, co the la mot dch t cung hay mau t cung co c
dau hieu bnh thng nhng benh nhan khong thng bieu hien bang hnh anh mot khoang noi
trieu chng (Hnh 15-17).70 Lng dch ln hn co mac gian, cha ay dch, ma co the cha chat co
the gap trong cac tnh trang lanh tnh, ma thng phan am (Hnh 15- 9). Kho phan biet tnh trang boi
gap nhat la lien quan en hep co t cung, hay tnh nhiem ( mu t cung) vi dch t cung tren sieu
trang ac tnh.71,72 Khi o noi mac t cung, khong am, va s dch t cung luon c chan oan bang
c tnh luon lp dch. Do dch cho phep quan sat lam sang.75
chi tiet hn noi mac t cung, rat quan trong e Tang san noi mac t cung. S tang san cua
anh gia noi mac can than e xem nhng bat noi mac t cung c xac nh la s tang sinh cac
thng va cac khoi dang polyp . tuyen vi hnh dang va kch thc khong eu, cung
dch t cung am ao va mau t cung vi viec tang t le tuyen/ mo em khi so sanh vi
am ao. S tac nghen cua ng sinh duc gay ra noi mac t cung tang sinh bnh thng. Qua trnh
viec lai cac chat tiet, mau, hay ca hai ben trong nay lan toa nhng co the khong anh hng en
t cung, va/ hoac am ao, vi v tr tuy thuoc vao toan bo noi mac t cung. Ve mat mo hoc, tang san
so lng tac nghen. Trc tuoi co kinh, s lai cac noi mac co the chia thanh tang san khong kem te
chat tiet trong am ao va t cung goi la dch t bao khong ien hnh va tang san kem te bao khong
cung - am ao. Sau khi co kinh, mau t cung - ien hnh (tang san khong ien hnh). Cac nghien
am ao tao ra do mau kinh b gi lai. S tac nghen cu theo doi trong thi gian dai a cho thay rang
co the la bam sinh va phan ln thng do mang khoang mot phan t cac trng hp tang san khong
trinh khong co lo thung. Cac nguyen nhan bam ien hnh se tien trien thanh carcinoma, ngc lai
sinh khac bao gom vach ngan am ao, hep am ao vi tang san khong kem theo te bao khong ien
hay sng t cung cha hoan thien. dch t cung hnh ch co di 2%. Moi loai nay co the chia nho
va mau t cung cung co the do hep co t cung v them thanh tang san n gian (dang nang) hay
cac u t noi mac hay t co t cung hoac t x hoa phc tap (dang u tuyen), tuy thuoc vao s phc tap
sau khi xa tr.71-75 va mat o cua tuyen. Trong tang san n gian
Tren sieu am, neu tac nghen ngang mc am (dang nang), cac tuyen gian dang nang va c
ao, se co s gian ang ke am ao va khoang noi bao quanh bi nhieu te bao mo em, ngc lai
mac do dch. Neu quan sat thi iem trc tuoi dang tang san phc tap (dang adenoma), cac tuyen
day th, s lai cac chat se co phan am trong. Sau tap trung lai, vi t mo em gia.
khi co kinh, s hien dien cua mau cu tao nen chat Tang san noi mac t cung la mot nguyen nhan
co phan am ben trong dch (Hnh 15-18). Cung co thng gap cua xuat huyet t cung bat thng.
the co mot lp chat co phan am, tao thanh mot Tang san phat trien t s kch thch khong oi
Hnh 15-19. mau t cung benh nhan hep co t cung th phat do carcinoma t
cung. A. Hnh cat doc gia tren nga bung cho thay t cung sau man kinh nho va kenh noi mac
cha ay dch (mui ten). B. Hnh sieu am nga am ao cho thay kenh noi mac mui ten gian, ay
dch vi dch cha chat co phan am mc o khac nhau, la ket qua cua mau va manh vun.
khang cua estrogen; phu n sau man kinh va

quanh tuoi man kinh, no thng do lieu phap thay
the hormone estrogen khong oi khang. S tang
san thng t gap hn tuoi sinh san, nhng no co
the xay ra nhng phu n co cac chu ky khong
rung trng lien tuc, benh buong trng a nang
va cac phu n beo ph vi tang san estrogen noi
sinh. Tang san co the thay nhng phu n co cac u
tiet estrogen, nh la cac u te bao hat (granuloma)
va cac u te bao vo (thecomas) cua buong trng.
Tren sieu am, noi mac t cung thng day va
co phan am vi cac b gii han ro (Hnh 15-9, E). Hnh 15-20. Polyp noi mac t cung. Hnh sieu am nga
Co the thay nhng nang nho trong noi mac am ao cho thay day khu tru noi mac ay t cung (c
trng hp tang san dang nang; tuy nhien, co the anh dau ben ngoai). Hnh anh nay khong ac hieu va cung
co the thay vi tang san khu tru va carcinoma. Noi mac
gap hnh anh tng t trng hp teo dang nang, than t cung mong va bnh thng.
va cac thay oi dang nang cung co the co trong cac
polyp noi mac t cung. Nhng vung nang nay a teo noi mac dang nang, nhng khi noi mac t cung
bieu hien ac trng cho cac tuyen gian dang nang day ta khong the phan biet hnh anh nay vi tang
thay tren mo hoc.76,77 Mac du cac thay oi dang san dang nang.78
nang ben trong noi mac t cung day thng gap Cac polyp noi mac t cung. Cac polyp noi
trong cac tnh trang lanh tnh hn, nhng ta co the mac t cung la nhng ton thng thng gap,
thay chung trong carcinoma noi mac t cung.78 thng thay hn nhng phu n quanh tuoi man
Teo noi mac t cung. Phan ln phu n xuat kinh va sau man kinh. Chung co the gay ra xuat
huyet t cung sau man kinh co teo noi mac t huyet t cung, mac du phan ln th khong co trieu
cung.61-65,79 Tren sieu am nga am ao, mot noi mac chng. phu n ang tuoi co kinh, chung co the
t cung thng mong, o di 5 mm, va cac benh bieu hien xuat huyet gia ky kinh , a kinh keo dai
nhan nay, khong can tham do hay ieu tr g them. va co the la mot nguyen nhan cua vo sinh. Ve mat
Ve mat mo hoc, nhng tuyen noi mac co the gian, mo hoc, cac polyp la s phat trien tai cho qua mc
nhng cac te bao hnh khoi det va mo em x hoa. cua mo noi mac t cung, c bao quanh bi bieu
Noi mac t cung mong vi cac thay oi dang nang mo va chung cha mot so lng khac nhau cac
tren sieu am nga am ao la chan oan chac chan tuyen, mo em va mach mau. Chung co the co
cuong hay co chan rong, hay co cuong mong. t cung, ky thuat nay ly tng e boc lo ro cac
Khoang 20% polyp noi mac t cung la a polyp. S polyp (Hnh 15-21, A en F).81,82 Sieu am buong t
thoai hoa ac tnh th khong thng gap. oi khi, cung cung la mot ky thuat co gia tr khi sieu am
polyp co mot cuong dai, cho phep no nho vao vung nga am ao khong the phan biet c mot polyp
co t cung va ngay ca vao trong am ao. noi mac t cung vi leiomyoma di niem mac
Tren sieu am, cac polyp co the trong nh day (Hnh 15-21, G va H). Ta co the thay polyp xuat
noi mac t cung, tang phan am, khong ac hieu, co phat t noi mac t cung, ngc lai, ta xem thay
the lan toa hay khu tru (Hnh 15-19, F va 15-20). mot lp noi mac bnh thng nam ben tren u x
Tuy nhien, chung cung co the co dang mot khoi co di niem mac.83
phan am, tron, khu tru ben trong khoang noi mac. Co the thay cac vung dang nang ben trong mot
(Hnh 15-19, H),80 va hnh anh nay cang de nhan ra polyp (Hnh 15-9, I) ac trng cho cac tuyen gian
hn khi co dch trong khoang noi mac bao quanh ve mat mo hoc.76,77 oi khi, ta co the thay ong
khoi. Bi v dch c truyen dan vao trong khoang mach nuoi ben trong cuong vi Doppler mau.
noi mac t cung trong suot luc lam sieu am buong
Hnh 15-21. Sieu am buong t cung. A. Polyp co phan am tron, gii han ro. B. Mot tham (carpet)
cac polyp nho. C. Polyp tren mot cuon. D. Polyp vi nhng vung dang nang. E. Polyp nho. F. Polyp nho. G.
U x di niem mac phan am kem. H. U x di niem mac giam am phan am kem. I. Dnh noi mac t
cung. Chu y cac dai mo bac cau ben trong kenh noi mac ay dch. (c phep cua Stephanie R. Wilson,
M.D.,University of Toronto)
Cac polyp noi mac t cung co the khong chan oan trong teo noi mac, tang san noi mac va cac
c khi nong va nao, v mot polyp tren mot cuong polyp, nhng cung co the thay carcinoma.78
de uon co the b bo sot khi nao. Neu xuat huyet Carcinoma noi mac cung co the gay tac kenh noi
bat thng van dai dang sau khi nong va nao khong mac, tao nen dch t cung hay mau t cung.
chan oan mot phu n sau man kinh co be day Mac du cac hnh anh sieu am co khuynh hng
noi mac t cung hn 8 mm, th sau o ta e ngh soi chac chan thien ve can nguyen lanh tnh hay ac
t cung e quan sat trc tiep khoang noi mac.84 tnh, nhng co nhng tnh chat trung lap, va thng
Carcinoma noi mac t cung. Carcinoma noi oi hoi phai co sinh thiet noi mac e chan oan
mac t cung la benh ly phu khoa ac tnh thng xac nh.
gap nhat Bac My, va ty le cua no ang gia tang. Tamoxifen, mot phc hp khang estrogen non-
No xay ra khoang 3% phu n nhng chiem di steroid, c s dung rong rai e ieu tr ho tr
1,5% trng hp t vong do ung th, bi v hn cho nhng phu n ung th vu trc va sau man
75% carcinoma gii han t cung vao thi iem kinh. Tamoxifen hoat ong bang cach canh tranh
bieu hien lam sang. Phan ln 75% en 80% vi estrogen tren cac thu the estrogen. cac phu
carcinoma noi mac xay ra phu n sau man kinh. n trc tuoi man kinh, no co tac dung khang
Bieu hien lam sang thng gap nhat la xuat huyet estrogen, nhng phu n sau man kinh, no co the
t cung, mac du ch co 10% phu n xuat huyet sau co nhng tac dung estrogen yeu. a co bao cao ve
man kinh se co carcinoma noi mac. Co s lien s gia tang nguy c carcinom noi mac nhng
quan chat che vi lieu phap estrogen thay the. benh nhan ieu tr tamoxifen, cung nh viec tang
phu n trc tuoi man kinh, nhng chu ky khong nguy c tang san noi mac va cac polyp noi mac.
rung trng va beo ph cung c xem nh la cac Tren sieu am, nhng thay oi noi mac lien quan
yeu to nguy c, tng t trong tang san noi mac t en tamoxifen khong ac hieu va tng t vi cac
cung. Khoang 25% benh nhan tang san noi mac thay oi c mo ta trong tang san, cac polyp, va
khong ien hnh se tien trien thanh carcinoma noi carcinom.87-89 Nhng thay oi dang nang ben trong
mac biet hoa cao.35 noi mac t cung day cung thng gap (Hnh 15-9,
Tren sieu am, mot noi mac t cung day phai F, I va Hnh15-23, A).
c xem la ung th en khi c chng minh mot so benh nhan ieu tr tamoxifen, nhng
ngc lai. Noi mac t cung day co the gii han ro, thay oi dang nang a thc s c chng minh co
phan am ong nhat, va khong phan biet c vi v tr di noi mac (Hnh 15-23, B) va co the ac
tang san va cac polyp. Ung th co nhieu kha nang trng cho nhng thay oi bat thng giong u c
xay ra hn khi noi mac t cung co cau truc phan tuyen lp trong c t cung.90
am khong ong nhat vi cac gii han khong eu Vai tro cua Doppler mau va Doppler pho trong
hay khong ro (Hnh 15-22). Nhng thay oi dang viec chan oan carcinoma noi mac van con gay
nang ben trong noi mac t cung thng gap hn tranh cai. Cac nghien cu ban au dung Doppler
Hnh 15-22. Carcinoma noi mac, cac hnh thai thay oi. Cac hnh sieu am nga am ao. A. Noi mac t cung day, khong
ong nhat (mui ten) vi nhng vung a nang nho. B. Day khu tru khong eu noi mac t cung (cac mui ten) vi cac nhu giong polyp
tang phan am, ben trong kenh noi mac ay dch (F).
Hnh 15-23. Tac dung cua Tamoxifen, cac hnh anh khac nhau. Cac hnh sieu am nga am ao. A,
Polyp dang nang (mui ten) benh nhan ieu tr Tamoxifen thi gian dai. B,Vung a nang (mui ten cong) ke can
noi mac t cung mong (mui ten) phu n sau khi man kinh ieu tr Tamoxifen thi gian dai. Hnh anh sieu am
khong thay oi trong khoang thi gian 9 thang va mau sinh thiet noi mac t cung 2 lan khac nhau cho thay ch
co teo noi mac lp trong c t cung.
mau va pho qua nga am ao a cho rang co the bang cach xac nh s xam lan c t cung.98-100 S
phan biet carcinom noi mac vi noi mac t cung nguyen ven cua vong sang lp di niem mac
sau man kinh bnh thng hay lanh tnh nh s (lp trong cua c t cung) thng la dau hieu cua
hien dien cua dong mau tr khang thap trong ong viec xam lan nong, ngc lai, mat vong sang bao
mach t cung phu n b ung th noi mac, khi so hieu s xam lan sau.98 MRI co the cung hu ch e
sanh vi dong mau co tr khang cao cac phu n anh gia s xam lan c t cung. Sieu am nga am
co noi mac t cung bnh thng hay lanh tnh.91,92 ao va MRI khong tiem th T2 c bao cao la
Tuy nhien, cac bao cao sau o a cho thay khong co o chnh xac tng t101 nhng khi chng minh
co s khac biet quan trong nao dong mau trong s xam lan c t cung ngi ta tin la MRI co tiem
t cung gia cac u noi mac lanh tnh va ac tnh.93-95 chat tng phan tot hn ca hai cach tren.102 MRI
Ngi ta cung a bao cao rang dong ong mach t cung co the anh gia s xam lan co t cung. Co le
cung co tr khang thap co lien quan en cac u x sieu am giup xac nh giai oan carcinom va giup
t cung.92 Cac bao cao gan ay hn a anh gia phan biet gia cac u con gii han t cung (giai
dong mau noi mac va di noi mac, cung nh oan I va II) vi cac u a lan rong ra ngoai t cung
mot so nha nghien cu a tm thay s khac biet (giai oan III va IV).99 CT cung hu dung e xac
ang ke gia nhng ton thng noi mac lanh tnh nh giai oan ung th, bang cach boc lo ro hach
va ac tnh, vi cac khoi ac tnh bieu lo dong mau ph ai va di can xa (giai oan III hoac IV).
tr khang thap trong cac ong mach lp noi mac Viem noi mac t cung. Viem noi mac t
va lp di noi mac.68,96 Ngoai ra, khi anh gia cac cung co the xay ra trong thi ky hau san, sau viec
ong mach nay, ngi ta a khong tm thay s nong va nao, hay lien quan en benh ly viem
khac nhau ang ke.94,95,97 Kho phat hien dong mau nhiem vung chau. Tren sieu am, noi mac t cung
noi mac t cung bnh thng. Sladkevicius va cs. bieu hien day, khong eu, hay va day va khong
a nhan thay be day noi mac t cung la mot cach eu, va buong t cung co the co hay khong co
e phan biet noi mac t cung bnh thng va benh dch. (Hnh 15-24). Co the thay kh vi bong lng
ly, hoac lanh tnh va ac tnh tot hn Doppler cua pha xa trong kenh noi mac. Tuy nhien, kha nang
cac ong mach t cung, lp di noi mac hay gap kh len en 21% phu n bnh thng ve mat
trong lp noi mac.95 Cac nghien cu sau hn tren lam sang, 3 tuan au hau san khi sanh qua nga
so ong benh nhan can thiet e xac nh xem am ao khong bien chng.103 Do o, khi thay kh
Doppler co vai tro khi phan biet gia cac u noi mac noi mac t cung cua benh nhan hau san, phai ket
lanh tnh vi ac tnh. hp vi lam sang.
Sieu am co the c dung e anh gia trc Dnh noi mac t cung. Dnh noi mac t cung
mo mot benh nhan co carcinoma noi mac t cung co the la mot nguyen nhan cua vo sinh hay h thai
Hnh 15-24. Viem noi mac t cung, nhng hnh anh khac nhau. Cac hnh cat doc gia tren nga bung. A,
Mc dch-dch (mui ten) ben trong kenh noi mac benh nhan co benh ly viem nhiem vung chau. ieu nay c giai
quyet sau khi ieu tr khang sinh. B, bang quang. B, Nhieu vach phan am day (mui ten cong) vi bong lng do kh ben
trong kenh noi mac cang (mui ten) benh nhan hau san b sot.
tai phat. Sieu am chan oan kho khan tr khi dch cac dung cu tranh thai trong t cung. Sieu am co
cang len trong khoang noi mac. Noi mac t cung the bieu lo s sai v tr, s xuyen thung va s lay
luon co bieu hien bnh thng tren sieu am nga khong het dung cu tranh thai trong t cung. V tr
bung va nga am ao, mac du qua nga am ao, ton lech tam cua mot dung cu tranh thai trong t cung
thng dnh co the thay di dang khong eu an gi y s xuyen c. Neu khong thay mot dung cu
hay mot dai phan am kem, giong nh bac cau ben tranh thai trong t cung tren sieu am nen chup
trong noi mac t cung. Hnh anh nay c thay ro Xquang e anh gia xem cac dung cu tranh thai
nhat trong suot giai oan che tiet, khi noi mac t trong t cung nam t do trong khoang phuc mac
cung phan am manh hn. Sieu am buong t cung la hay khong co vong, do a c lay ra trc o.
ky thuat tot nhat e xac nh dnh noi mac, khi dch Cac dung cu tranh thai trong t cung co the b che
c truyen dan vao trong khoang noi mac. Dnh khuat bi cac bat thng ben trong t cung i kem
noi mac trong nh cac dai mo bac cau, lam bien nh la mau cuc hay viec say thai khong hoan toan.
dang buong t cung (Hnh 15-21, I), hay nh cac Khi co mot dung cu tranh thai trong t cung cung
mang mong, gn song, thay ro nhat bang cac ky vi mot thai trong t cung, ta co the thay ro rang
thuat thi gian thc. Phan dnh co chan rong, day cac dung cu tranh thai trong t cung au tam ca
co the ngan can buong t cung cang ra. Co the nguyet th nhat, nhng hiem khi xac nh c
tach phan dnh khi soi t cung cac thi iem sau o. tam ca nguyet th nhat,
Cac dung cu tranh thai trong t cung. Cac cac dung cu tranh thai trong t cung thng co the
dung cu tranh thai trong t cung de dang bieu lo lay ra an toan di hng dan cua sieu am.
tren sieu am (Hnh 15-25). Chung co dang cac cau
truc dang ng thang phan am day trong khoang Cac bat thng cua co t cung
noi mac vung than t cung. Mot vai loai dung cu Kho anh gia ay u vung co t cung bang sieu
tranh thai trong t cung bieu lo hnh dang ac am nga bung, v no nam thap trong vung chau, pha
trng tren sieu am, phan anh hnh thai chung cua sau bang quang. Vi sieu am nga am ao, ta quan
chung. Phai phan biet cac dung cu tranh thai trong sat c tot hn, ac biet neu au do co the rut lai
t cung vi phan am bnh thng, mc o manh mot phan va be goc ve pha sau neu t cung gap
trung tam cua khoang noi mac. Luon thay bong trc , hay be ve pha trc neu t cung gap sau.
lng t cac dung cu tranh thai trong t cung, va Nhng bat thng cua co t cung thng c
cung co the thay hai ng phan am song song chan oan bang lam sang. Cac nang Naboth (the
(hnh phan chieu vao-ra), la mat trc va sau cua vui) cua co t cung thng thay khi sieu am thng
Hnh 15-25. Dung cu tranh thai ben trong t cung. Cac hnh cat doc gia tren nga bung. A, Cau truc dang ng
thang phan am day (mui ten) v tr bnh thng trong kenh noi mac vung than t cung. B, Cac om co phan am, ngat quang
trong kenh noi mac vung than t cung. Hnh anh ien hnh cua vong Lippes. C, Dung cu tranh thai ben trong t cung (mui ten)
nam kenh co t cung. D. Dung cu tranh thai thai ben trong t cung (mui ten) mot t cung co thai tuan th 30. F, thai. B,
bang quang.
Hnh 15-26. Cac nang Naboth. Cac hnh sieu am nga am ao. A, Nang Naboth n oc vung co t
cung. Kenh noi mac vung co t cung (mui ten). B, Nhieu nang Naboth vung co t cung.
qui (Hnh 15-26). Chung co the thay oi kch thc c, no co the boc lo mot co t cung bnh thng.
t vai mm en 4 cm. Chung co the co mot hay Hep co t cung co the la th phat sau xa tr trc
nhieu nang va thng c chan oan ngau nhien, o, sinh thiet non trc o, teo co t cung sau man
nhng co the lien quan en viem co t cung man kinh, hoac carcinoma co t cung.
tnh ang lanh. oi khi cac nang Naboth co phan Carcinoma co t cung thng c chan
am ben trong, co the do xuat huyet hay nhiem oan bang lam sang, va hiem khi benh nhan c
trung. Nhieu nang co the la nguyen nhan ph ai tham khao y kien anh gia cua sieu am. Sieu am
lanh tnh cua co t cung.106 co the xac nh mot u ac sau bang quang , ma ta
Cac polyp co t cung la mot nguyen nhan gay co the phan biet vi mot u x vung co (Hnh 15-
xuat huyet am ao thng gap, va co the thay tren 28). Co the dung sieu am e phan giai oan, nhng
sieu am (Hnh 15-27). Tuy nhien, chung thng CT va MRI c a chuong hn.
c chan oan bang lam sang. Khoang 8% u c
trn xuat phat t vung co. Chung co the co cuong AM AO
va sa vao trong am ao. cac benh nhan a cat t
cung, phan con lai cua co t cung oi khi gia hnh T co t cung, am ao chay ve pha trc va pha
anh mot u. Sieu am nga am ao thng chan oan chan, gia bang quang va trc trang. No c thay
ro nhat tren sieu am khi cat doc tai ng gia, vi
viec be nhe goc au do ve pha chan. No trong nh
mot cau truc ong xep phan am kem, vi mot ng
thang phan am day trung tam, ac trng cho hai
mat niem mac am ao tiep xuc nhau (hnh 15-2).
Bat thng bam sinh thng gap nhat cua ng
sinh duc n la mang trinh khong co lo thung, gay
ra mau am ao. oi khi, ngi ta dung sieu am
e quan sat ac iem mot khoi am ao. Cac
nang ong Gartner la phan con lai cua ong trung
than, tao nen mot hay nhieu nang doc theo thanh
ben hay trc ben cua am ao (hnh 15-29). ay la
nhng ton thng dang nang thng gap nhat cua
Hnh 15-27. Polyp co t cung. Sieu am nga am ao cho
am ao va thng c tm thay ngau nhien trong
thay polyp co phan am (p) c bao quanh bi dch kenh co
t cung. qua trnh sieu am. Hiem gap cac khoi dang ac
Hnh 15-28. U x va carcinoma co t cung 2 benh nhan khac nhau, vi mot hnh anh tng t.
Hnh cat doc gia qua nga bung. A, Co t cung ph ai, khong ong nhat (mui ten) do carcinoma co t cung. Noi mac
t cung c anh dau ben ngoai. B, bang quang.
Hnh 15-31. Dch tang phan am tui cung sau (mui

Hnh 15-29. Nang ong Gartner. Hnh cat doc gia cho
ten) do mau. Hnh sieu am qua nga am ao.
thay khoi dang nang (mui ten) thanh am ao.
NGACH TRC TRANG T CUNG (TUI

CUNG SAU)
Tui cung sau la phan pha sau va pha trong nhat

cua khoang phuc mac. No nam gia trc trang va
am ao, va cung c goi la tui cung Douglas.
Vom am ao pha sau co lien quan chat che vi tui
cung sau va c ngan cach bi be day cua thanh
am ao va phuc mac. Tui cung sau la mot khoang
ao, va do v tr cua no, ay thng la v tr au tien
tu dch trong phuc mac. Ch can 5 cc dch la sieu
am nga am ao co the phat hien ra.109
Dch tui cung la dau hieu bnh thng cac
phu n khong co trieu chng lam sang va co the
thay c dch trong tat ca cac giai oan cua chu
ky kinh nguyet. Nhng nguyen nhan co the co a
Hnh 15-30. Khoi ac (M) trong am ao. Hnh cat doc
c tha nhan bao gom mau hay dch tao ra do v
gia. Khi phau thuat, khoi nam nam doc thanh trc am ao, nang, mau do mau kinh chay ngc lai va tang
va ve benh hoc, la u x t cung. B, bang quang. tnh tham mao mach be mat buong trng di
anh hng cua estrogen.110,111
Ngi ta thay tu dch benh ly tui cung
am ao (Hnh 15-30). Ngi ta a mo ta hai trng Douglas co lien quan en bang bung noi chung,
hp neurofibroma (u x than kinh) cua am ao mau t thai ngoai t cung v hoac nang xuat huyet
bieu hien di dang cac khoi ac.107 Tng t nh hoac mu do nhiem trung. Sieu am co the giup phan
carcinoma cua co t cung, ngi ta khong dung biet loai dch v mau, mu, chat nhay, va cac chat
sieu am e chan oan carcinoma am ao, nhng co tiet ac tnh thng co phan am ben trong dch,
the dung sieu am e phan chia giai oan. ngc lai, thanh dch (ca sinh ly hay benh ly)
cac benh nhan a cat t cung, khong nen thng phan am trong. Mau cuc co the co phan am
nham lan mom cut am ao vi mot khoi. Gii han rat tang. Sieu am nga am ao cho thay cac phan
tren cua mc bnh thng ng knh trc sau am ben trong dch thng hn v o phan giai cua
mom cut am ao la 2,1 cm.108 Mot mom cut ln no a c cai thien. (Hnh 15-31).113
hn 2,1 cm hay co cha mot khoi ro rang se gi y Nhng ap xe hay mau tu vung chau co the gap
la khoi ac tnh. Cac vung dang not co the do x tui cung sau, va hnh anh sieu am tng t vi ap
hoa sau xa tr. xe hay mau tu cac ni khac trong c the.
kch thch cua hormone kch thch nang (FSH) va

hormone hoang the hoa (LH), nhieu nang phat
trien va tang kch thc cho en khoang ngay th 8
hay cua chu ky kinh nguyet. Tai thi iem o, mot
nang phat trien troi len, danh rieng e phong noan,
va tang kch thc, at t 2,0 en 2,5 cm thi
iem rung trng. Cac nang khac nho lai. Mot nang
noan phat trien neu dch mot trong cac nang troi
nay khong c tai hap thu. Sau khi rung trng,
hoang the phat trien va co the xac nh c tren
sieu am nh mot cau truc nho ong phan am hay
Hnh 15-32. Buong trng bnh thng. Hnh sieu am phan am kem ngoai bien buong trng. Hoang the
nga am ao mot phu n cha man kinh cho thay buong trng thoai trien trc khi hanh kinh.
(mui ten) vi mot vai nang ngoai bien. Tnh mach chau
trong (I) c thay pha sau buong trng. Do a dang ve hnh the, the tch buong trng
c xem la cach tot nhat e xac nh kch thc
BUONG TRNG buong trng. Viec o the tch da tren cong thc
cua mot elp dai ra (0,523 x dai x rong x cao). Cac
Giai phau sieu am bnh thng nghien cu gan ay a cho thay la the tch buong
V tr cua t cung anh hng en v tr cua hai trng ln hn ta ngh trc o. Trong 2 nam au
buong trng. Hai buong trng bnh thng thng i, the tch trung bnh cua buong trng hi ln hn
nam pha ngoai hay sau ngoai neu t cung tai 1 cc nam au va 0,7 cc nam th hai.114 Ngi ta
ng gia, nga trc. Khi t cung nam ve mot bao cao gii han tren cua mc bnh thng la 3,6
ben ng gia (mot bien the bnh thng), buong cc trong 3 thang au, 2,7 cc 4 en 12 thang, va
trng ben o thng nam tren ay t cung. mot 1,7 cc trong nam th hai.114 The tch buong trng
t cung gap sau, hai buong trng co khuynh hng gi tng oi on nh cho en 5 tuoi va sau o tang
nam pha ngoai va pha tren, gan ay t cung. Khi dan cho en ky kinh nguyet au tien, khi o the
t cung ln, hai buong trng co khuynh hng di tch trung bnh la 4,2 2,3 cc, va gii han toi a la
lech len tren va ra ngoai hn. Sau khi cat t cung, 8,0 cc. Nhng nang nho thng thay buong trng
hai buong trng co khuynh hng nam hi vao tre s sinh va trc tuoi day th. Chung thng o
trong va ngay pha tren mom cut am ao. di 9 mm nhng co the ln en 17 mm.115
Do cho bam cua day chang long leo, v tr phu n tuoi trng thanh, ang tuoi co kinh,
buong trng co the kha thay oi va no co the nam mot buong trng bnh thng co the tch ln
cao trong vung chau hay tui cung. V buong trng khoang 22 cc. Cohen va cong s a anh gia 866
co v tr thay oi, hai buong trng nam pha tren buong trng bnh thng bang sieu am nga bung va
hay ra xa pha ngoai co the khong the thay c a bao cao the tch mot buong trng trung bnh la
bang sieu am au do am ao, do chung ngoai 9,8 5,8 cc, vi mot gii han toi a 21,9 cc. Mot
trng quan sat. Hai buong trng co dang elp, vi nghien cu khac tren 406 benh nhan co buong
truc au-uoi song song vi cac mach mau chau trng bnh thng bang sieu am nga am ao, a
trong, la cac mach mau nam pha sau va ong vai ghi nhan the tch mot buong trng trung bnh la 6,8
tro nh cot moc quan trong. (Hnh 15-32). cac cc, vi gii han toi a la 18,0 cc.117
benh nhan co u x t cung, mot so nha nghien cu Thnh thoang co the thay voi hoa khu tru
a co the quan sat hai buong trng bang sieu am mot buong trng hnh dang bnh thng khac, va
nga am ao thng xuyen hn la bang nga bung.7,8 ngi ta ngh no bieu hien phan ng mo em vi
Tren sieu am, buong trng bnh thng co tnh trang xuat huyet hay nhiem trung trc o.
mot cau truc phan am tng oi ong nhat vi Tuy nhien, voi hoa co the bieu hien sm hay khi
vung tuy trung tam co phan am nhieu hn. Co the au cua mot khoi tan sinh, do o ngi ta e ngh
thay nhng nang nho, phan am trong gii han ro sieu am theo doi.
ngoai bien, trong vung vo. Hnh dang cua buong
trng thay oi theo tuoi va theo giai oan cua chu Buong trng sau khi man kinh
ky kinh nguyet. Suot au giai oan tang sinh, di Sau khi man kinh, buong trng teo lai va cac nang
Hnh 15-33. Buong trng bnh thng sau khi man

kinh. Hnh sieu am nga am ao cho thay buong trng bnh
thng sau khi man kinh (mui ten). Chu y en kch thc nho Hnh 15-33. Nang buong trng sau khi man kinh.
va khong co nang. Hnh cat doc gia 1 phu n 75 tuoi cho thay nang buong
trng 4cm (mui ten) pha sau t cung (u). Nang khong co
bien mat trong mot vai nam sau o, vi viec giam phan am hay phan vach ben trong va khong thay oi kch
kch thc buong trng khi tuoi tang.119-121 Do kch thc trong 2 nam.
thc buong trng nho hn va khong co cac nang,
co the kho nhn thay buong trng sau man kinh Mot nghien cu anh gia 563 benh nhan co cac
tren sieu am (Hnh 15-33). Co the nham lan mot buong trng bnh thng sau khi man kinh, bang
quai ruot khong chuyen ong vi mot buong trng sieu am nga am ao a bao cao the tch mot buong
bnh thng; do o, phai khao sat sieu am mot trng trung bnh la 2,0 cc vi gii han tren cua mc
cach cham rai e tm nhu ong. Theo tai lieu bnh thng la 8,0 cc. The tch mot buong trng
nghien cu, viec thay c tren sieu am hai tren 8,0 cc chac chac phai xem la bat thng.
buong trng bnh thng tuoi sau man kinh thay Vai tac gia cho rang the tch mot buong trng gap
oi rat nhieu, t mc thap 20% en mc cao 99%, hai lan the tch buong trng ben oi dien cung nen
khi dung sieu am nga bung hay nga am ao. S c xem la bat thng, bat ke en kch thc that
thay oi co le do khac biet ve mat ky thuat va o s.120,122
dai thi gian ke t luc man kinh, v kha nang nhn Cac nang sau khi man kinh. Cac nang nho
thay buong trng giam cung vi o dai thi gian phan am trong (ng knh nho hn 3 cm) co the
ke t luc man kinh. Cung vay, viec khong co t thay 15% cac buong trng sau khi man kinh va
cung cung gi vai tro quan trong, v hau nh t quan khong lien quan en tuoi, o dai thi gian sau ke
sat thay hai buong trng sau khi cat t cung do mat t khi man kinh, hay noi tiet s dung (Hnh 15-
cac moc giai phau bnh thng. Wolf va cs., trong 34).124 Nhng nang nay thng gap hn qua sieu
mot nghien cu tren 290 buong trng c biet la am nga am ao do o phan giai c cai thien cua
con sau khi man kinh, dung ca sieu am nga bung no, nhng mot vai phu n, ac biet nhng phu
va nga am ao, ch thay c buong trng qua nga n a cat t cung hay co cac buong trng nam cao,
am ao 41% va qua nga bung 58% trng hp. co the ch thay cac nang qua sieu am nga bung.
Viec dung ca hai ky thuat se quan sat thay buong Nhng nang nay co the bien mat hay thay oi kch
trng nhieu hn khi ch dung mot ky thuat (68%). thc theo thi gian.125
Cac buong trng nam cao, co the ra khoi trng Vai nghien cu a cho thay t le ac tnh rat
quan sat cua au do am ao, va sieu am nga bung thap nhng nang sau man kinh ch co mot thuy,
co the khong u nhay e xem nhng buong trng o ng knh di 5cm va khong phan vach hay
qua nho. Viec khong quan sat thay mot buong co cac thanh phan ac.126-129 Ngi ta e ngh theo
trng khong loai tr c kha nang co ton thng doi nhng benh nhan nay bang vec khao sat sieu
buong trng o. am nhieu lan, khong can thiep phau thuat tr khi
Nhng nghien cu khac nhau ve mat kch co s tang kch thc hay thay oi cac tnh chat
thc a cho thay the tch buong trng trung bnh cua ton thng.129 Phau thuat c e xuat cho cac
t 1,2 cc en 5,8 cc.116,117,119-123 Cac gia tr trung nang sau man kinh ln hn 5 cm va cho cac nang
bnh trong nhng nghien cu nay co le hi cao, v co phan vach va/ hoac co cac not dang ac ben
tnh luon ca cac buong trng khong quan sat thay. trong.
Hnh 15-35. Nang xuat huyet, cac hnh anh khac nhau. Hnh sieu am nga am ao. A, Hoang the nho
xuat huyet cha chat co phan am vi mot mc dch-dch (mui ten). Nang nho phan am trong ke ben (C) . B,
Nang ln co nhieu phan am mc o thap ben trong. C, Hnh dang li cua cac phan am ben trong va cac vach
ngan ben trong nang (mui ten). D, Mau cuc co phan am bieu th s co cuc mau (mui ten) ben trong nang.
Nhng ton thng khong tan sinh en toi a vao 8 en 10 tuan, va nang thng mat
Cac nang chc nang. Cac nang chc nang i thai 16 tuan.
cua buong trng bao gom u nang, nang hoang the Tren sieu am, nhng nang chc nang ien hnh
va nang hoang tuyen. Mot u nang xuat hien khi la cac cau truc phan am trong, mot thuy, vi thanh
mot noan trng thanh khong rung hay khong thoai mong, gii han ro va co tang am pha sau.
trien. U nang co kch thc t 1, 0 cm en 20, 0 Cac nang xuat huyet. Xuat huyet ben trong
cm. Tuy nhien, v cac noan bnh thng co the thay co the xay ra vi ca hai loai nang chc nang, mac
oi t vai mm en 2 cm va co the at en 2,5 cm du thng thay nhieu hn nang hoang the. Nhng
khi trng thanh, nen khong the chan oan chac phu n co cac nang xuat huyet thng khi au
chan mot u nang cho en khi kch thc cua no hn cn au vung chau cap tnh. Cac nang xuat huyet
2,5 cm.130 Chung thng xay ra mot ben, khong cho thay mot loat dau hieu do hnh anh sieu am
trieu chng, va thng c phat hien ngau nhien khac nhau cua mau (Hnh 15-35). Hnh anh sieu
tren sieu am. U nang chc nang thng t thoai am tuy thuoc vao lng mau chay va gi xuat
trien. huyet so vi gi khao sat sieu am. Nhng ac tnh
Nang hoang the (corpus luteal cyst) tao ra do ben trong nang c anh gia ro hn nhieu qua
s khong hap thu hay do xuat huyet qua mc vao sieu am nga am ao do o phan giai cua no a
trong hoang the. Chung thng t gap hn nang c c cai thien. Mot nang xuat huyet cap tnh
nang, nhng co khuynh hng to hn va bieu hien thng phan am manh va co the trong giong mot
trieu chng nhieu hn. au la trieu chng chu yeu. khoi dang ac. Tuy nhien, no thng co mot thanh
Nhng nang nay thng xay ra mot ben va de xuat sau eu va bieu hien tang am pha sau, cho thay
huyet va v. Neu trng c thu tinh, hoang the tnh chat dang nang cua ton thng. Khi co s ly
duy tr lien tuc nh la hoang the cua thai ky, co giai hong cau cua mau cuc , hnh dang ben trong
the tr nen ln va co dang nang. Kch thc at tr nen hon hp hn, vi dang li, cha phan am
va cac vach ben trong. Co the thay mot ng ranh Cac nang can buong trng (can voi
gii hay mc dch-dch gia thanh phan mau cuc trng). Cac nang can buong trng chiem khoang
va dch. Mau cuc co phan am cung co the lang 10% tat ca cac khoi phan phu. Chung c tm
xuong phan thap cua nang. S co mat cua dch t thay trong day chang rong va thng co nguon goc
do co phan am trong phuc mac tui cung sau co trung bieu mo hay can trung than, hay hiem gap
the giup khang nh chan oan mot nang xuat co nguon goc t trung than.134 Chung co the co
huyet r hay v. Mot nang xuat huyet v co the bat c tuoi nao, nhng thng gap nhat thap nien
giong nh mot thai ngoai t cung v, ca ve mat th ba va th t cua cuoc song. Chung thay oi ve
lam sang lan sieu am. kch thc, va tren sieu am co hnh anh ien hnh
Nhng nang chc nang la nguyen nhan cua cac nang (Hnh 15-36). Chung thng nam
thng gap nhat lam ln buong trng cac phu pha tren so vi ay t cung134 va co the co phan
n tre.130 V phan ln nhng nang chc nang ien am ben trong do xuat huyet. Nang co the xoan va
hnh se mat i sau mot en hai chu ky kinh, nen v tng t nh cac khoi dang nang khac. Nhng
thng khong can theo doi cac nang nho, n gian. nang can buong trng khong thay oi theo chu ky.
Tuy nhien, co the theo doi cac nang ln hn hay Mot chan oan ac hieu ch co the co khi thay
cac nang co xuat huyet nhng thi iem khac buong trng cung ben bnh thng nam sat, nhng
nhau cua chu ky kinh, thng trong vong 6 tuan, e tach biet vi nang.136
thay s bien oi hnh thai hoac bien mat. Cac nang vui trong phuc mac. Cac nang
Nang hoang tuyen (theca-luteal cyst)la nhng vui trong phuc mac xay ra nhieu nhng phu n
nang chc nang ln nhat va i kem vi mc cha man kinh vi mot benh s phau thuat o bung
gonadotropin nhau (HCG) cao. Nhng nang nay trc o, nhng cung co the gap chung tren cac
xay ra ien hnh cac benh nhan co benh ly mang benh nhan co benh s chan thng, benh viem
nuoi cua thai nhng cung co the gap hoi chng vung chau hay lac noi mac t cung. Cac buong
kch thch buong trng qua mc do bien chng cua trng la nguon chu yeu tao ra dch phuc mac
dung thuoc ieu tr vo sinh. Tren sieu am, nang phu n. nhng benh nhan co dnh phuc mac, dch
hoang tuyen thng co hai ben, a thuy, va rat co the tch tu ben trong vung dnh va bao lay cac
ln. Chung co the xuat huyet, v, va xoan. buong trng, tao nen mot khoi phan phu ln.137,138
Hoi chng di tch buong trng. t gap, la Cac nang vui trong phuc mac c lot bi cac te
mot khoi dang nang benh nhan a c cat bo bao trung bieu mo; tnh trang nay c goi la u
hai buong trng; trong o, mot lng nho mo trung bieu mo dang nang lanh tnh hay dch ong
buong trng con lai b bo sot. Phau thuat thng ken lanh tnh. Ve lam sang, phan ln benh nhan
gap kho khan ve mat ky thuat do dnh t lac noi bieu hien au va/ hoac mot khoi vung chau.
mac t cung, benh viem vung chau, hay khoi u. Mo
buong trng con lai b kch thch bi noi tiet to, va
tao nen mot nang chc nang xuat huyet.133
Hnh 15 36. Nang can buong trng. Hnh cat doc gia Hnh 15 37. Nang vui trong phuc mac. Hnh sieu
tren nga bung cho thay nang ln (C) nam pha ben phai cua t am nga bung cho thay nhieu vung dang nang cha nhieu
cung va bang quang (B). Hnh sieu am nga am ao cho thay dch (c) vi cac vach ngan mong eu (mui ten), ac trng
nang tach biet khoi ca hai buong trng. cho cac vung dnh bam vao buong trng bnh thng (o)
Tren sieu am, cac nang vui trong phuc mac la cac Dang khu tru bao gom mot khoi rieng biet goi
khoi phan phu dang nang nhieu thuy (Hnh 15-37). la mot u lac noi mac t cung, hay nang so co la.
Dau hieu chan oan la s hien dien cua mot buong Mac du lac noi mac t cung thng i kem vi vo
trng nguyen ven gia cac vach ngan va dch. sinh, oi khi co the thay mot u lac noi mac t cung
Dau hieu nay ch ro nguon goc ngoai buong trng mot benh nhan co thai. U lac noi mac t cung
cua khoi. Buong trng co the trung tam hay lech thng khong co trieu chng va thng co nhieu u.
ra ngoai bien, va du co ve b bien dang, van de Hnh anh sieu am ac trng la mot khoi gii han
dang xac nh c buong trng. Cac vach tieu ro, mot thuy hay a thuy, chu yeu dang nang, cha
bieu cho cac si trung bieu mo va cac si dang x phan am lan toa, ong nhat, mc o thap ben trong
thay tren giai phau benh. Dch thng phan am (Hnh 15-38). Hnh anh nay c xac nh ro hn
trong nhng co the co phan am trong mot vai thuy nhieu qua sieu am nga am ao.140 Cac cau truc ben
do xuat huyet hoac dch co protein. Ngi ta e trong vi phan am mc o thap nay thay lan toa
xuat ieu tr bao ton v cac nang vui (inclusion khap khoi hay trong vung thap. oi khi co the thay
cyst) trong phuc mac khong co tiem nang ac tnh. mc dch-dch.
Lac noi mac t cung. Lac noi mac t cung Hnh anh co the tng t vi mot nang buong
c nh ngha la co mo chc nang cua noi mac trng xuat huyet v ca hai eu la nhng khoi dang
ben ngoai t cung. Lac noi mac t cung thng xay nang co cha mau giai oan khac nhau.141 Tuy
ra nhat buong trng, voi trng, day chang rong, nhien, mot nang xuat huyet ben trong thng hay
va tui cung sau, nhng no cung co the xay ra hau bieu hien di dang li hn va thng i kem vi
nh bat c vung nao khac trong c the, bao gom dch t do tui cung. Mot nang xuat huyet se mat
bang quang va ruot. Co hai dang c mo ta: lan i hay bieu hien viec giam kch thc ang ke qua
toa va khu tru (u lac noi mac t cung). Dang lan vai chu ky kinh nguyet ke tiep, ngc lai, lac noi
toa, thng gap hn, bao gom nhng mo nho cua mac t cung co khuynh hng bieu hien s thay
noi mac t cung cay vao trong cac tang vung chau oi t ve kch thc va dang phan am ben trong.
va vao cho bam cac day chang cua chung. Mo noi Cac u lac noi mac t cung hay cac nang xuat huyet
mac lac cho ap ng vi hormone va xuat huyet khi bieu lo nhng tnh chat t ien hnh co the gay
trong suot thi gian hanh kinh, gay ra phan ng nham lan vi mot u buong trng hay ap xe tai voi
viem cung vi dnh tai cho. Dang lan toa nay hiem buong trng. Ve mat lam sang, phan ln phu n co
khi c chan oan bang sieu am do cac manh mo mot nang xuat huyet cap tnh co cn au vung
ghep qua nho en mc khong the thay c. Lac chau cap tnh, ngc lai, phu n co mot nang lac
noi mac t cung thng anh hng en ngi phu noi mac t cung th khong co trieu chng hay co
n trong suot tuoi sinh san va cac trieu chng lam nhng kho chu kinh nien hn cung vi kinh nguyet
sang bao gom thong kinh, giao hp au, va vo sinh. cua ho.
Hnh 15-38. U lac noi mac t cung, hnh thai ien hnh. Cac hnh sieu am qua nga am ao . A,
Hnh anh ien hnh cua u lac noi mac t cung vi cac vung phan am mc o thap, ong nhat, lan toa trong
khoi dang nang (mui ten) kem tang am nhe pha sau . B, Dang phan am ong nhat ben trong (E) vi mc
dch-dch (mui ten).
Hnh 15-39. Benh buong trng a nang, hnh thai ien hnh. Cac hnh sieu am qua nga am ao. A,
Buong trng tron, ln (mui ten) phan am mo em tang va nhieu nang ngoai bien; dau hieu chuoi ngoc. B, Buong
trng ln (mui ten) vi nhieu nang ngoai bien va trung tam . I, Tnh mach chau trong .
Benh buong trng a nang. Benh buong chan oan khong chac chan hay benh nhan
trng a nang (polycystic ovarian disease=PCOD) khong b nghi ng ve mat lam sang. V s rung
la mot roi loan phc tap ve hormone, gay ra tnh trng khong xay ra, cac nang se ton tai trong chuoi
trang khong rung trng man tnh. Mat can bang cac nghien cu. Viec theo doi trong thi gian dai
cua LH va FSH lam cho san xuat estrogen va c e xuat nhng benh nhan nay v cac mc
androgen b bat thng.130 Mc LH huyet thanh estrogen cao khong oi khang dng nh kem theo
tang va mc FSH giam; ty le LH/FSH tang la mot nguy c tang carcinom noi mac t cung va vu.
dau hieu ac trng. Ve benh hoc, cac buong trng Xoan buong trng. Xoan buong trng la mot
co mot so lng nang tang, cac giai oan trng tnh trang bung cap oi hoi phai can thiep phau
thanh va teo i khac nhau, va co s tang tap trung thuat ngay lap tc. Xoan do s xoay mot phan hay
khu tru androgen, tao ra s bat thng mo em. hoan toan cuong buong trng tren truc cua no.
PCOD la mot nguyen nhan vo sinh thng gap. ieu nay dan en bat thng dan lu mach bach
Hoi chng co ien Stein-Leventhal (kinh nguyet t, huyet va tnh mach, gay ra sung huyet va phu nhu
chng ram long, beo ph) ch la mot dang trong mo buong trng va cuoi cung dan en mat ti
mot loat nhng bieu hien lam sang cua PCOD. mau ong mach va hau qua la nhoi mau. Xoan co
Nhng dau hieu sieu am ien hnh la buong the xay ra cac buong trng bnh thng hay kem
trng hai ben ln cha nhieu nang nho va o phan theo mot nang hay khoi buong trng a co trc
am cua mo em tang (Hnh 15-39). Cac buong o. Khoi thng hau nh luon lanh tnh.146 Viec
trng co hnh dang tron hn, vi cac noan thng xoan mot buong trng bnh thng hay xay ra tre
nam ngoai bien, mac du chung cung co the ngau em va cac phu n tre hn, vi phan phu ac biet di
nhien co nhu mo buong trng. Sieu am nga am ong, cho phep xoan mac treo voi trng.147 Xoan
ao, do o phan giai tot hn cua no, nhay hn khi thng xay ra tuoi nien thieu va suot tuoi sinh
phat hien cac nang nho. Cac nang co kch thc o san. Nguy c tang trong suot thai ky. Ve lam sang,
c t 0,5 en 0,8 cm, vi hn nam nang moi co cn au vung chau d doi, buon non va non. Co
buong trng.142 Tuy nhien, nhng dau hieu ien the s thay mot khoi. Neu au ben phai, xoan
hnh nay c thay trong t hn phan na so benh buong trng co the giong ve mat lam sang vi
nhan co tnh trang nay. The tch buong trng bnh viem ruot tha cap.
thng co khoang 30%.142,143 Viec ket hp kch Cac dau hieu sieu am thay oi, tuy thuoc vao
thc nang trung bnh va the tch buong trng c mc o bat thng mach mau va co mot khoi
nhan thay la nhay va ac hieu hn la ch co mot phan phu hay khong (Hnh 15-40). Buong trng
tnh chat. Khi dung sieu am nga am ao, ngi ta ln. Nhieu nang vo trong mot buong trng ln
tin rang o phan am cua mo em tang la dau hieu c xem la mot dau hieu chuyen biet, mac du
nhay nhat va ac hieu nhat cua benh buong trng khong thng gap.147 S ln len vi nhieu nang do
a nang.au2144,145 Thng chan oan c nh sinh viec r dch vao trong nang t viec suy tuan hoan.
hoa, nhng sieu am hu ch trong nhng trng hp Sieu am Doppler mau va Doppler pho co the cho
Hnh 15-40. Xoan buong trng. A, Hnh cat doc gia

qua nga bung mot be gai 16 tuoi b au bung di trai cap
tnh cho thay khoi phan phu ln, cha nhieu nang phan am
trong ngoai bien (mui ten). B, Bang quang B, Hnh sieu am
qua nga bung mot benh nhan song thai 28 tuan b au bung
di phai cap tnh cho thay buong trng phai ln ang ke
(mui ten) vi mot vai nang phan am trong ngoai bien.
Doppler khong thay dong mau .C, Buong trng trai bnh
thng (mui ten) benh nhan trong hnh B .
thay khong co dong mau trong buong trng b anh phu n Hoa Ky. Nam 1995, c tnh khoang
hng. Tuy nhien, cac dau hieu Doppler co the 26.000 trng hp ung th buong trng mi c
thay oi tuy thuoc vao mc o va s keo dai cua chan oan Hoa Ky, va co khoang 14.500 ca t
xoan va co hay khong mot khoi phan phu kem vong.154 Ung th buong trng chiem 25% toan bo
theo. Ngi ta thay s hien dien cac dang song cac ung th phu khoa, vi ty le cao nhat cua no
ong mach va dong mau tren Doppler cac trng xay ra thap nien th sau cua cuoc song. Mac du
hp a c chng minh la xoan khi phau thuat. ch la ung th phu khoa thng gap th ba, no co t
Co the giai thch la do tac nghen tnh mach dan le t vong cao nhat do viec chan oan tre. Khi co
en cac trieu chng trc khi viec tac ong mach mot vai trieu chng lam sang, khoang 60% en
xay ra va dong ong mach lien tuc phan phu co 70% phu n co benh a tien trien (giai oan III hay
lien quan en s cung cap mau kep cho ong mach IV) tai thi iem chan oan. T le song 5 nam noi
buong trng (t ong mach buong trng va cac chung la 20% en 30%, nhng vi viec phat hien
nhanh cua ong mach t cung).150 sm giai oan I, t le tang en 80%. Do o,
Phu nang buong trng. ay la mot tnh nhng no lc nham hng vao viec phat trien cac
trang hiem gap, gay ra do xoan mot phan hay tng phng phap chan oan sm tnh trang nay .
t cua buong trng, tao nen s tac tnh mach va Tuoi tang, cha sanh con, mot benh s ve ung
mach bach huyet, nhng khong tac ong mach. th vu, ung th noi mac t cung, hay ung th ai
ieu nay gay nen ph ai buong trng do phu mo trang, hay mot benh s gia nh ve ung th buong
em ang ke. Mot vai trng hp c mo ta tren trng kem theo nguy c cao hn ve s phat trien
sieu am cho thay mot khoi phan phu ln, gom chu ung th buong trng. Benh s gia nh c xem
yeu nhieu nang.151-153 nh yeu to nguy c quan trong nhat. Nguy c phat
trien ung th buong trng trong cuoc i mot phu
Nhng khoi tan sinh n la 1/70 (1,4%). Tuy nhien, neu mot phu n co
Ung th buong trng. Ung th buong trng la mot ngi ho hang the he th nhat (me, con gai,
nguyen nhan xep th t dan en t vong do ung th ch em gai) hay mot ngi ho hang the he th hai
(d hay ba) b ung th buong trng, th t le la 5%. thuan NIH ve ung th buong trng c to chc
Vi hai hay nhieu ngi ho hang hn, nguy c nam 1994 a ket luan rang khong co bang chng
trong i tang len en 7%.155 Khoang 3% en 5% san co nao ve viec cac phng phap tam soat hien
phu n co mot benh s gia nh b ung th buong tai bang CA 125 va sieu am nga am ao co the
trng se co mot hoi chng ung th buong trng di c dung hu hieu nham tam soat rong rai e lam
truyen. Ba hoi chng di truyen chnh kem theo ung giam t vong do ung th buong trng; cung nh
th buong trng la hoi chng ung th vu-buong khong co bang chng ve viec s dung chung se
trng, thng gap nhat, trong o co tan suat b ca lam giam hay lam tang benh tat va t vong. Viec
hai ung th cao; hoi chng ng th ai-trc tam soat thng qui dan en phau thuat khong can
trang khong do benh polyp di truyen (Lynch II) thiet vi cac nguy c co tiem an kem theo no.*
trong o ung th buong trng xay ra cung vi ung Ve mat mo hoc, nhng u bieu mo chiem 65%
th ai-trc trang khong polyp hay ung th noi mac en 75% cac u buong trng va 90% cac ung th
t cung hoac ca hai; t gap nhat la hoi chng ung buong trng. Nhng u con lai bao gom cac u te bao
th buong trng v tr ac hieu, khong co ung th mam (15% - 20%), cac u cot gii tnh-mo em (5%
vu hay ai trc trang them vao.156 - 10%), va cac u di can (5% - 10%) (Bang 15-1).
Ngi ta ngh la hoi chng ung th buong trng Tren sieu am, ung th buong trng thng
di truyen co s tha ke mot nhiem sac the troi, va bieu hien la mot khoi phan phu. Sieu am phan
nguy c b ung th buong trng trong i nhng anh tnh trang hnh thai hoc ai the cua u, nhng
benh nhan nay khoang 40% en 50%. Ho co tuoi khong phan anh ve mat mo hoc. Do o, that kho
khi au benh sm hn (10 en 15 nam) so vi cac phan biet nhng u buong trng lanh tnh va ac tnh
ung th buong trng khac.156 bang sieu am. Cac ton thng gii han ro, phan am
Ngi ta a bao cao mot so th nghiem tam trong co kha nang lanh tnh hn, ngc lai, nhng
soat lam sang nhng phu n phan ln sau man ton thng co cac thanh khong eu, day, co cac
kinh, khong co trieu chng.157-160 Cac th nghiem vach khong eu, co cac not thanh, va co nhng
nay tap trung vao cac marker u ve sinh hoc nh CA thanh phan dang ac co phan am se thien ve ac
125 va tren sieu am, au tien la nga bung va gan tnh. Ngi ta a e ngh nhng he thong tnh iem
ay hn la au do trong am ao. CA 125 la mot da tren cac ac iem ve hnh thai hoc.170-172 Cac
glycoprotein trong lng phan t cao c nhan ra he thong nay an nh gia tr bang so cho cac dau
bi khang the n dong OC 125. No a chng to hieu sieu am rieng biet; so iem cang cao, kha
rat hu dung khi theo doi dien tien lam sang cua nang ac tnh cang cao. Tuy nhien, cac tac gia khac
cac benh nhan ang trai qua hoa tr va trong viec nhau a an nh nhng gia tr bang so khac nhau
phat hien benh ly tien lam sang tai phat. Mac du cho cac dau hieu bat thng, gay ra kho khan khi
CA 125 huyet thanh tang khoang 80% phu n co so sanh cac he thong. Cung vay, nhng ton thng
ung th bieu mo buong trng, no phat hien di lanh tnh nh cac nang xuat huyet va cac u quai co
50% benh giai oan I va khong nhay oi vi cac the co thanh day khong eu, cac not thanh va
u nhay va cac u te bao mam. Cung vay, cac ung cac thanh phan ac, co so iem cao, va nh vay,
th khac cung nh vai tnh trang lanh tnh co the chan oan ac tnh la sai .
kem theo tang CA 125 huyet thanh.162,163 Do o, Nhng dau hieu Doppler cua ung th
viec dung CA 125 huyet thanh nh mot phng buong trng. Gan ay hn, sieu am Doppler mau
phap tam soat a gay that vong. Cac nghien cu va Doppler xung a ho tr cho viec phan biet cac
ket hp CA 125 vi sieu am c khuyen khch khoi buong trng lanh tnh vi ac tnh. S ho tr
hn. Nhng th nghiem sang loc gan ay hn bao da tren mot luan iem la cac khoi ac tnh, do s
gom sieu am mau va Doppler xung cong them vi tan sinh mach mau ben trong, se co dong tam
sieu am nga am ao tren cac phu n khong co trng cao, co the c phat hien c tren cac
trieu chng, cac phu n co benh s gia nh ung dang song Doppler pho (Hnh 15-41). S tang
th buong trng hay ng th khac, va phu n co trng cua u ac tnh tuy thuoc vao s tao mach
ung th vu trc o. Hien tai, viec dung sieu am mau, vi viec phat trien cac mach mau u bat
e tam soat ung th buong trng van c xem nh thng.173 Nhng mach mau bat thng nay khong
giai oan nghien cu va khong c e xuat * Hoi ngh ong thuan NIH. Ung th buong trng: tam soat, ieu tr va
theo doi.. JAMA 1995;273:491-497
dung thng qui tren lam sang. Mot hoi ngh ong
co c trn ben trong cac thanh cua chung, cung vi thng ac tnh.175,176,179-182
s thong noi ong tnh mach, dan en tr khang Nhng thong so khac, nh v tr mach mau va
mach mau giam va nh vay, van toc dong tam s hien dien cua mot cho lom th tam trng, a
trng cao hn. Hai ch so khong phu thuoc goc, gi y la cai thien c o ac hieu trong viec anh
ch so xung (PI) va ch so tr khang (RI), c gia cac khoi buong trng bang Doppler.188 Cac ton
dung e phan tch kieu dang song Doppler. PI la ty thng ac tnh co khuynh hng co dong mau
so gia van toc trung bnh vi hieu so gia van toc trung tam nhieu hn, ngc lai nhng ton thng
nh tam thu vi van toc cuoi tam trng; RI la ty lanh tnh co khuynh hng co dong mau ngoai
so gia van toc nh tam thu va hieu so gia van bien nhieu hn. Tuy nhien, Stein va cong s a
toc nh tam thu vi van toc cuoi tam trng. nhan thay s trung lap ang ke, vi 21% cac ton
Nhng nghien cu ban au ve viec dung thng ac tnh ch co dong mau ngoai bien va
Doppler mau va Doppler xung qua nga am ao a 31% cac ton thng lanh tnh co dong mau trung
noi rang ca hai eu co o nhay cao va o ac hieu tam.181 S hien dien mot cho lom th tam trng
cao khi phan biet cac khoi buong trng lanh tnh va la dau hieu cua c trn bnh thng ben trong
ac tnh, vi nhng khoi ac tnh co ch so xung di thanh mach mau, ma khong co nhng ton thng
1.0 hay ch so khang tr di 0,4.174-177 Tuy nhien, ac tnh. Tuy vay, dau hieu nay cung thng khong
nhieu nghien cu sau o a khong the tao ra lai o co trong nhng ton thng lanh tnh, nh vay khong
nhay va o ac hieu cao nh vay va a cho thay co dau hieu th khong co y ngha chan oan .
co s trung lap ang ke gia nhng ton thng Mot so bao cao a so sanh cac tnh chat hnh
lanh tnh va ac tnh.178-187 Khi phan loai ton thng, thai hoc tren sieu am vi cac dau hieu Doppler va
phan ln cac tac gia a dung ch so xung hay ch so nhan thay rang Doppler khong them bat ky thong
tr khang thap nhat thu c, cho la gia tr cua tnh tin chan oan nao hn la anh gia n thuan ve
huong xau nhat, v ieu nay co the tng ng vi hnh thai hoc.182-184 Nhng bao cao khac a nhan
dau hieu ac tnh duy nhat ve mat mo hoc.177,178 thay rang Doppler, khi a giup them cho viec anh
cac phu n tuoi con kinh nguyet, dang song gia hnh thai hoc tren sieu am, se cai thien o ac
cua ong mach buong trng thay oi tuy theo giai hieu va gia tr d oan dng tnh. Doppler co le
oan cua chu ky kinh. Suot giai oan hanh kinh va khong can thiet neu nh u co mot hnh thai ac
giai oan tang sinh, co mot kieu dong mau tr ien hnh lanh tnh, v sieu am chnh xac cao
khang cao. Vi s phat trien cua hoang the gia nhom ton thng nay.181-185 Doppler co le co gia tr
chu ky, quan sat thay kieu dang song tr khang khi anh gia mot u ma khong xac nh c ve mat
thap do cac mach mau mi tao ra doc theo thanh hnh thai hay gi y ac tnh. Tuy nhien, khong nen
cua hoang the. Nhng mach mau nay cung khong dung cac dau hieu Doppler n le ma nen ket hp
co c trn va bieu hien dong tam trng cao, tr vi viec anh gia hnh thai hoc, nhng dau hieu
khang thap, tng t nh s tan sinh mach mau u. lam sang, tuoi benh nhan, va giai oan cua chu ky
Do o, cac phu n tuoi con kinh nguyet, ngi ta kinh e anh gia tot nhat mot khoi phan phu .
e ngh lam sieu am Doppler gia ngay th 3 va Cac u bieu mo-mo em be mat. Cac u bieu
10 cua chu ky kinh e tranh lam lan vi dong mo-mo em be mat (surface epitheluial-stromal
hoang the bnh thng . tumors) noi chung c xem la xuat phat t bieu
Mac du phan ln cac bao cao a nhan thay ca mo be mat bao boc buong trng va mo em ben
ch so xung va ch so tr khang co khuynh hng di buong trng. Co the chia nhng u nay thanh
thap hn cac ton thng ac tnh, nhng cung co nam nhom ln da tren s khac biet bieu mo:
rat nhieu s trung lap khi phan biet chac chan gia thanh dch, nhay, dang noi mac t cung, te bao
nhng ton thng lanh va ac tnh trong rieng le sang, va te bao chuyen tiep (Brenner). Nhom
tng benh nhan. Mot vai tac gia a nhan thay cac u nay chiem 65% en 75% tat ca u buong
khong co gia tr ngng ac hieu cho ca ch so trng va 80% en 90% tat ca ung th buong trng.
xung hay ch so tr khang ma chung co ca o nhay Co mot nhom trung gian khoang 10% en 15% cac
cao va o ac hieu cao. Khong co dong mau ben u thanh dch va nhay ma c phan loai ve mat mo
trong mot ton thng thng la dau hieu cua mot hoc la giap bien hay co tiem nang ac tnh thap.
ton thng lanh tnh, nhng mot vai bao cao u cho Cac u nay co nhng tnh chat te bao hoc ac tnh,
thay cung khong co dong mau ben trong cac ton nhng khong xam lan mo em va du la ac tnh
Hnh 15-41. Ung th buong

trng, ong gop cua Doppler
cac benh nhan khac nhau. A,
Hnh sieu am qua nga am ao
cho thay mot khoi chu yeu dang
nang, ln, phan vach nhieu, vi
cac phan dang ac co phan am.
B, Tren cung benh nhan nh A
Doppler pho qua vung mach mau
trong phan co phan am (cho anh
dau), cho thay dong tam trng
A!
tang. Ch so xung PI thap nhat
at c la 0,59 va ch so tr
khang RI 0,4 . C, Doppler mau
qua nga am ao cho thay cac
vach co mach mau trong mot
khoi nhieu nang . D, Doppler
mau qua nga bung cho thay tuan
hoan trong mot khoi chu yeu
dang ac (M) .
Hnh 15-42. Cystadenoma thanh dch, cac hnh anh khac nhau. Cac hnh sieu am qua nga am ao A, Khoi
buong trng dang nang ln vi cac vach mong va cac cau truc phan am mc o thap ben trong . B, Khoi dang nang ln vi
cau truc dang ac co phan am (mui ten) va nhieu phan phan am mc o thap ben trong. Hnh anh sieu am cung khong the
phan biet vi ac tnh .
Hnh 15-43. Cystadenocarcinoma thanh dch, cac hnh anh khac nhau . A, Hnh sieu am qua nga am ao cho
thay mot khoi dang nang ln, cha nhieu cac truc phan am mc o thap ben trong va cac thanh phan dang ac co phan am
(mui ten). B, Hnh sieu am qua nga bung cho thay mot khoi lng dang nang ln vi cac not thanh, co phan am, dang ac,
khong eu (mui ten) va cac phan phan am mc o thap ben trong .
van co mot tien lng tot hn. Kieu lan rong cua buong trng.35 Tan suat nh cua cystadenoma
cac u ac tnh au tien la vao ben trong phuc mac, thanh dch la vao khoang 40 en 50 tuoi, ngc lai
mac du s lan rong trc tiep vao cac cau truc lan cystadenocarcinoma thanh dch thng xay ra nhat
can va s lan rong theo ng bach huyet th phu n quanh tuoi man kinh va sau khi man kinh.
khong thng gap. Viec lan rong theo ng bach Khoang 20% cac cystadenoma thanh dch lanh tnh
huyet chu yeu en cac hach quanh ong mach chu. va 50% cac cystadenocarcinoma thanh dch ac tnh
S lan rong theo ng mau thng xay ra giai b hai ben. Kch thc cua chung thay oi nhieu,
oan tre cua benh . nhng noi chung chung nho hn cac u nhay .
Cystadenoma thanh dch va cystadeno- Tren sieu am, cystadenoma thanh dch thng
carcinoma thanh dch. Cac u thanh dch thng la cac khoi ln, thanh mong, dang nang, mot thuy,
gap nhat, chiem 30% tat ca u buong trng. Khoang co the co cac vach ngan mong (Hnh 15-42).Thnh
50% en 70% cac u thanh dch la lanh tnh. thoang quan sat thay cac nhu nho ra. Cystadeno-
Cystadenoma thanh dch chiem 20% en 25% tat carcinoma thanh dch co the kha ln va thng
ca u buong trng lanh tnh va cystadenocarcinoma bieu hien la cac khoi dang nang, nhieu thuy, cha
thanh dch chiem 40% en 50% tat ca ung th nhieu nhu nho ra t cac thanh va cac vach ngan
Hnh 15-44. Cystadenoma nhay A, Hnh sieu am qua nga bung cho thay mot khoi ln,
dang nang nhieu vach mong (mui ten) va cac cau truc phan am mc o thap ben trong. B, Mau
benh hoc ln cho thay nhieu ngan dang nang .
cua nang (Hnh 15-43). Cac vach ngan va cac ay phan ln vung chau va o bung (Hnh 15-45).
thanh co the day. Co the thay cau truc dang ac co Co the thay chat co phan am mc o thap ben
phan am ben trong cac thuy. Cac nhu nho ra co the trong dch. Tnh trang nay co the xay ra
hnh thanh tren be mat cua nang va cac c quan cystadenoma nhay va cystadenocarcinoma nhay.
xung quanh, tao nen s bam chat cua khoi. Thng Mot nang niem dch cua ruot tha v va carcinoma
quan sat thay dch bung . ai trang di can cung co the dan en u nhay gia
Cystadenoma nhay va cystadenocarcinoma phuc mac .
nhay. Cac u nhay la u bieu mo buong trng thng U dang noi mac t cung. Gan nh tat ca cac u
gap th hai, chien 20% en 25% cac u buong dang noi mac t cung eu ac tnh. Chung la ung
trng. Cystadenoma nhay chiem 20% en 25% tat th bieu mo thng gap th hai, chiem 20% en
ca cac u buong trng lanh tnh va Cystadeno- 25% cac ung th buong trng.35 Khoang 25% en
carcinoma nhay chiem 5% en 10% tat ca u buong 30% co hai ben. Cac ac tnh mo hoc cua chung
trng ac tnh nguyen phat.35 Chung thng t gap giong vi cac ac tnh mo hoc cua adenocarcinoma
hai ben hn la cac u thanh dch tng ng, vi ch noi mac t cung va 30% benh nhan co tnh trang
co 5% cac ton thng lanh tnh va 15% en 20% nay kem theo adenocarcinoma noi mac t cung,
cac ton thng ac tnh xay ra hai ben. Khoang ma c ngh la mot u nguyen phat rieng biet. U
85% cac u nhay la lanh tnh. dang noi mac t cung co tien lng tot hn cac ung
Tren sieu am, cystadenoma thanh dch co the th bieu mo khac, co le do chan oan c giai
la cac khoi dang nang ln, o en 15-30 cm va oan sm hn. Tren sieu am, no thng hien dien
chiem toan bo vung chau va o bung. Co nhieu nh mot khoi dang nang cha cac nhu nho ra, mac
vach mong va co the thay cac cau truc phan am du trong mot so trng hp, co mot khoi chu yeu la
mc o thap do chat nhay trong cac vung thap cua dang ac, co the cha cac vung xuat huyet hay
khoi (Hnh 15-44). t gap cac nhu nho ra hn so vi hoai t.191,192
cac u thanh dch tng ng. Cystadenocarcinoma U te bao sang (clear cell tumor). U nay c
nhay thng la cac khoi dang nang ln, nhieu thuy, xem la co nguon goc t ong Muller va la mot bien
cha cac nhu nho ra va chat co phan am; noi the cua carcinoma dang noi mac. No gan nh luon
chung, chung co hnh anh sieu am tng t nh ac tnh va chiem 5% en 10% carcinoma buong
hnh anh cua Cystadenocarcinoma thanh dch . trng nguyen phat. No xay ra hai ben trong
S xam nhap vo bao u hay v u co the dan en khoang 20% cac benh nhan. Tren sieu am, no
viec lan rong cac te bao tiet nhay vao trong phuc thng bieu hien nh mot khoi hon hp, khong ac
mac, lap ay khoang phuc mac vi chat gelatin. hieu, chu yeu dang nang,191,192
Tnh trang nay c goi la u nhay gia trong phuc U te bao chuyen tiep (Brenner). U nay bat
mac, co the tng t vi dch bung tren sieu am, nguon t bieu mo be mat a trai qua d san e tao
hay co the co nhieu vach ngan trong dch ma lap nen cac thanh phan giong nh bieu mo nieu ien
ba lp te bao mam c biet hoa ro ngoai b,

trung b va noi b. Do cac thanh phan ngoai b noi
chung chiem u the, nhng u quai dang nang
thng thc s lanh tnh va cung c goi la nhng
nang b (dermoid cyst). Cac u quai dang nang va
cac cystadenoma thanh dch la hai loai u buong
trmg thng gap nhat. oi lap vi cac u bieu mo-
mo em be mat, nhng u quai dang nang thng
gap tuoi hoat ong sinh san, nhng chung co the
xay ra bat ky tuoi nao, va khong thng gap
phu n sau khi man kinh. Cac bien chng bao gom
Hnh 15-45. U gia nhay phuc mac (pseudomyxoma
xoan va v. Xoan la bien chng thng gap nhat,
pneumotei). Hnh sieu am cat ngang bang nga am ao qua
tui cung Douglas cho thay cac gii han khong the xac nh
ngc lai, v th t gap; xay ra khoang 1% trng
c. Co mot hnh anh hon hp dang nang va dang ac. Mot hp va gay viem phuc mac hoa hoc th phat. S
so tui dch th trong phan am trong va cac tui khac th ln chuyen thanh ac tnh cung khong thng co, xay ra
cn.(Courtesy of Stphenie R. Wilson, M.D., ai hoc mc khoang 2% cac trng hp, thng cac
Toronto.)
phu n ln tuoi hn.35
hnh.35 Khong thng gap, chiem 1% en 2% tat ca Tren sieu am, nhng u quai dang nang co mot
cac u buong trng va gan nh luon luon lanh tnh; hnh anh thay oi t phan am trong hoan toan en
6% en 7% co hai ben. Phan ln benh nhan phan am manh hoan toan. Tuy nhien, mot t tnh
khong co trieu chng va u c phat hien ngau chat c xem la ac hieu (Hnh 15-47 va Hnh 15-
nhien tren sieu am hay khi phau thuat. Ba chuc 48). Nhng tnh chat nay bao gom mot khoi chu
phan tram co kem theo cac u dang nang, thng la yeu dang nang vi mot not co phan am thanh,
cac cystadenoma thanh dch hay nhay hay cac tera- goi la nut b195(dermoid plug). Nut b thng
toma dang nang, thng buong trng cung ben cha toc, rang, hay m va thng cho mot bong
(Hnh 15-46).193 Tren sieu am, nhng u Brenner la lng am. S tng quan vi cac hnh anh CT a
cac khoi dang ac phan am kem. Co the co voi cho thay rang trong nhieu trng hp, thanh phan
hoa thanh ben ngoai. Cac vung dang nang th nang la ba nhn thuan tuy (ma co dang long
khong thng gap va khi hien dien th thng do nhiet o co the) hn la dch.196
co mot cystadenoma cung ton tai. Ve mat benh Mot hon hp cua toc ben lai va ba nhn co
hoc, chung la cac u ac bao gom mo em dang si phan am cao do nhieu giao dien mo, va no tao
day ac. Chung trong tng t nh nhng fibroma bong lng am xac nh khong ro, lam che m
buong trng va cac thecoma va leiomyoma t
cung, ca ve mat sieu am va benh hoc .
Cac u te bao mam (germ cell tumor). Cac u
te bao mam xuat phat t cac te bao mam nguyen
thuy cua phoi-sinh duc. Chung chiem 15% en
20% cac u buong trng, vi khoang 95% la cac u
quai dang nang lanh tnh. Nhng u khac, bao gom
u bieu mo mam cha biet hoa va cac u xoang noi
b (tui noan hoang), xay ra chu yeu tre em va cac
ngi ln tre va gan nh luon luon ac tnh. Cac u
te bao mam la ung th buong trng thng gap
nhat tre em va ngi ln tre. Khi mot khoi buong
trng ln, chu yeu ang ac hien dien mot be gai
hay mot phu n tre, chan oan mot u te bao mam
ac tnh nen c ngh nhieu en.194 Hnh 15-46. U Brenner thanh cua mot
U quai dang nang. Nhng teratoma dang nang cystadenoma nhay. Hnh sieu am qua nga bung cho thay
mot khoi ln, xac nh ro, dang nang (C) vi mot dang ac
chiem khoang 15% en 25% cac u buong trng;
phan am kem thanh (mui ten). Giai phau benh cho thay mot
10% en 15% co hai ben. Chung co nguon goc t u Brenner trong thanh cua mot cystadenoma nhay ln.
thanh sau cua ton thng. Thuat ng goi la dau phat trien nhanh vi tieu lng xau nay la u te bao
hieu nh cua nui bang.197 O phan am manh vi mam ac tnh buong trng thng gap th hai sau
bong lng xac nh ro co the do cac thanh phan u te bao mam cha biet hoa. Ngi ta ngh rang
khac, bao gom rang va xng. Co the thay hnh chung xuat phat t carcinoma phoi khong biet hoa
anh nhieu ng thang phan am manh troi ben va a tiem nang do s biet hoa chon loc ve pha tui
trong nang va bieu hien cho cac si toc. Hnh anh noan hoang va cac cau truc noan hoang. No
nay cung c xem nh mot dau hieu ac trng va thng xay ra cac phu n di 20 tuoi va phan
c goi la li b 199(dermoid mesh). Co the ln thng co mot ben. Co the thay mc alpha-
thay mc m-dch hay toc-dch va o cung c fetoprotein huyet thanh (AFP) tang kem theo u
xem la ac hieu. Mot u b co phan am co the hien nay. Hnh anh sieu am tng t vi hnh anh cua u
len tng t hi ruot va co the b bo sot. Neu lam te bao mam.
sang s thay mot khoi vung chau ro rang va sieu Cac u cot gii tnh-mo em (sex cord-
am co ve bnh thng, nen sieu am lai benh nhan, stromal tumor). Cac u cot gii tnh mo em xuat
chu y tm kiem ky lng mot u b. phat t cac cot gii tnh cua phoi-sinh duc va /
Bu giap buong trng (Struma Ovarii) la hoac t mo em buong trng. Cac u chu yeu
mot u quai ma cha toan bo hay chu yeu la mo nhom nay gom u te bao hat, u te bao Sertoli-
tuyen giap. No xay ra 2% en 3% cac u quai. Leydig (u nguyen bao nam tnh), u te bao vo va u
Mac du hiem khi co nhng anh hng noi tiet kem si. Nhom nay chiem 5% en 10% tat ca cac u
theo, sieu am co the co gia tr trong viec xac nh buong trng va 2% tat ca ung th buong trng.
mot ton thng vung chau mot benh nhan cng U te bao hat (granulosa cell tumor). U nay
giap khi khong co bang chng cua mot ton thng chiem khoang 1% en 2% cac u buong trng va co
tuyen giap co. tiem nang ac tnh thap. Phan ln xay ra phu n
Cac u quai cha trng thanh chiem di sau khi man kinh; gan nh tat ca co mot ben.
1% tat ca cac u quai va cha mo cha trng thanh Chung la u buong trng co hoat ong Estrogen
cua ba lp te bao mam. Chung la cac u ac tnh thng gap nhat,35 va cac bieu hien lam sang cua
phat trien nhanh ma thng xay ra nhat hai thap viec tiet estrogen co the xay ra. Khoang 10% en
nien au cua cuoc song. Tren sieu am, nhng u 15% cac benh nhan co u nay cuoi cung se phat
nay hien dien nh nhng khoi dang ac. trien carcinoma noi mac t cung. Tren sieu am,
U te bao mam (dysgerminoma). U te bao mam nhng u nay thay oi t cac khoi nho en cac khoi
la nhng u te bao mam ac tnh ma chiem khoang rat ln. Cac khoi nho chu yeu dang ac, co o
1% en 2% cac u buong trng nguyen phat va 3% phan am tng t o phan am cua nhng u x t
en 5% cac ung th buong trng.35 Chung cha cung. Cac khoi ln hn co dang nang va a thuy,
nhng te bao mam khong biet hoa va ve mat hnh co hnh anh tng t hnh anh cac cystadenoma.191
thai hoc th tng t nh u tinh hoan an ong. U te bao Sertoli-Leydig (androblastoma). ay la
Chung nhay cam cao vi tia xa va co ty le song 5 mot u hiem gap, chiem di 0,5% cac u buong
nam la 75% en 90%. U nay xay ra chu yeu phu trng. Noi chung, no xay ra cac phu n di 30
n di 30 tuoi va khoang 15% cac trng hp co tuoi; hau nh tat ca xuat hien mot ben. Ung th
u hai ben. U te bao mam va u nang tuyen thanh xay ra 10% en 20% cac u nay. Tren lam sang,
dch la hai u buong trng thng thay nhat thai cac dau hieu va trieu chng nam hoa xay ra
ky.191 Tren sieu am, chung la cac khoi dang ac, nhieu benh nhan, mac du khoang phan na benh
phan ln co phan am, nhng co the cha cac vung nhan se khong co cac bieu hien ve noi tiet.35 Thnh
nho phan am trong do xuat huyet hay hoai t (Hnh thoang, nhng u nay kem theo viec tiet ra
15-49).194 CT va MRI a cho thay cac khoi dang estrogen. Tren sieu am, chung co hnh anh tng t
ac nay phan thuy vi cac vach si co mach mau vi hnh anh cac u te bao hat (granulosa cell).
gia cac thuy. Mot bao cao gan ay dung Doppler U te bao vo va u si (thecoma & fibroma). Xuat
mau ba u te bao mam cha biet hoa cho thay phat t mo em buong trng va co the kho phan
dong ong mach noi bat ben trong cac vach si co biet chung vi nhau ve benh hoc. Cac u co nhieu
mach mau cua mot khoi a thuy, dang ac, co te bao vo c xep la u te bao vo, ngc lai,
phan am.202 nhng u co cac te bao vo t hn va nhieu mo si
U tui noan hoang (xoang noi b). U hiem gap, c phan loai la u vo-si hay u si. Nhng u te
Hnh 15-47. Cac u quai dang nang (nang b, dermoid cysts). A va B. Cac hnh sieu am qua nga
bung; C-I. Cac hnh sieu am qua nga am ao. A, Mot khoi dang nang vi mot vung co phan am mc o cao, co
bong lng pha sau. B, nh cua nui bang, mot khoi phan am manh, vi bong lng pha sau xac nh khong
ro. C, Nut b, mot khoi dang nang vi not dang ac, co phan am thanh. D, Khoi co phan am khac nhau
mc toc-dch va nut b cha m co phan am manh vi bong lng. E, Mot khoi vi mc m-dch. F, Mot khoi
phan ln co phan am vi mc m dch. G, Mot khoi co mc phan am ong nhat, mot vung nho dang nang, va
voi hoa vi bong lng. H, Mot khoi co mc phan am ong nhat cha mot o phan am mc o cao do rang vi
bong lng. I, Li b, hnh anh nhieu ng phan am manh troi ben trong mot khoi dang nang.
Hnh 15-49. U quai dang nang (cystic teratoma).

Mau benh hoc cho thay mot khoi buong trng ln cha
dch, m, toc, va rang.
phan biet chnh la u Brenner hay u x t cung co

cuong. Khong phai tat ca u si va u te bao vo bieu
hien hnh anh ac trng nay, va ngi ta a ghi
nhan thay cac hnh anh sieu am khac nhau, co le
do khuynh hng phu va s thoai hoa nang xay ra
ben trong nhng u nay (Hnh 15-51).204
Cac u di can. Khoang 5% en 10% cac u
buong trng co nguon goc do di can. Nhng v tr
nguyen phat thng gap nhat cua di can buong
trng la do cac u cua vu va ng da day-ruot.
Nen dung thuat ng u Krukenberg cho nhng u
cha cac te bao signet ring tiet nhay ien hnh,
thng xuat phat t da day hay ai trang.
Carcinoma noi mac t cung thng di can en
Hnh 15-49. U te bao mam cha biet hoa buong trng, nhng co le kho phan biet carcinoma
(dysgerminoma). Hnh cat doc gia mot be gai 16 dang noi mac nguyen phat, nh a ban luan tren.
tuoi cho thay mot khoi ln dang ac, co phan am vung Tren sieu am, di can buong trng thng la nhng
chau (M) pha sau bang quang (B).
khoi dang ac hai ben, nhng chung co the tr
nen hoai t va co hnh anh hon hp, chu yeu dang
bao vo chiem khoang 1% tat ca cac u buong trng nang, giong nh cystadenocarcinoma nguyen phat
va 70% xay ra nhng phu n sau khi man kinh. (Hnh 15-52).205,206 Co the thay dch bang cac u
Chung thng co mot ben, phan ln thng lanh nguyen phat hay di can. Lymphoma co the anh
tnh, va thng bieu hien cac dau hieu lam sang hng en buong trng, thng dang gieo rac lan
cua viec tiet estrogen. Cac u si, chiem khoang 4% toa, thng co hai ben. Hnh anh sieu am la mot
cac u buong trng, lanh tnh, thng co mot ben, khoi dang ac, phan am kem tng t nh
va thng xay ra nhat cac phu n man kinh va lymphom cac ni khac trong c the.
sau khi man kinh. Khong giong nh nhng u te bao
vo, hiem khi chung kem theo viec tiet estrogen va VOI TRNG
do o, thng khong co trieu chng, cho du at
en mot kch thc ln. Dch bang c bao cao la Kho nhan dien voi trng bnh thng bang sieu am
co phan na so benh nhan u si co ng knh qua nga bung hay nga am ao tr khi bao quanh no
ln hn 5 cm.203 Hoi chng Meig (kem theo dch la dch. Voi trng bnh thng la mot cau truc gn
bang va tran dch mang phoi) xay ra 1% en 3% song, co phan am, rong khoang 8 en 10 mm, chay
cac benh nhan co u si buong trng, nhng khong t t cung ra pha sau ngoai e nam ben trong tui
ac hieu, cung a c bao cao la kem theo cac u cung sau gan buong trng. Khong thay c long
buong trng khac. Tren sieu am, nhng u nay co voi trng tr khi no cha ay dch.207 Hiem gap cac
mot hnh anh ac hieu (Hnh 15-50). Trong cac u bat thng ve s phat trien voi trng. Cac bat
nay, ta thay mot khoi phan am kem vi giam am thng cua voi trng bao gom thai, nhiem trung va
pha sau ro ret do mo si ong nhat. Chan oan tan sinh .
Hnh 15-50. U si buong trng. A. Hnh sieu am qua nga am ao cho thay mot khoi dang ac phan am
kem (mui ten) vi mot t giam am pha sau. B. Mau benh hoc cho thay tnh chat ac ong nhat cua u si.
Hnh 15-51. U vo-si (fibrothecoma) buong trng vi s thoai hoa

nang. Hnh cat doc gia qua nga bung cho thay mot khoi ln, chu yeu dang nang
vi cac vung ac co phan am (mui ten) nam pha tren bang quang (B). Giai phau
benh cho thay u vo-si vi nhieu vung thoai hoa nang.
Benh viem vung chau cac bien chng khi sanh va sau nao thai. S lan
Benh viem vung chau (pelvic inflammatory tran theo ng mau hiem gap nhng co the xay ra
disease = PID) la mot tnh trang thng gap, co t do lao. Benh viem vung chau thng hai ben,
le ang tang. No thng do cac benh lay lan qua ngoai tr khi b gay ra do b lan rong trc tiep t
ng sinh duc, thng nhat la do lau cau va qua trnh viem ke can, luc o no se xay ra mot
Chlamydia. Nhiem trung thng lan rong theo ben. S hien dien cua mot dung cu tranh thai trong
ng t co t cung va noi mac t cung. Cac t cung lam tang nguy c cua benh viem vung
nguyen nhan t gap hn bao gom s lan rong trc chau. Di chng lau dai bao gom au vung chau
tiep t cac ap xe ruot tha, tui tha; hay ap xe sau man tnh, vo sinh va tang nguy c thai ngoai t
phau thuat v vao trong vung chau, cung nh cung .
Hnh 15-52. Di can buong trng, cac hnh anh khac nhau. A, Cat nga bung cho thay khoi u buong trng
dang ac, phan am giam (mui ten), di can t carcinoma vu. B, Sieu am nga am ao cho thay khoi hon hp, chu
yeu dang nang kem vach ngan va nhng vung ac tang phan am (mui ten). Mac du hnh anh sieu am tng t nh
ung th buong trng nguyen phat, chan oan benh hoc la di can buong trng t ung th nguyen phat trc trang.
Benh viem vung chau truyen qua ng sinh

duc lan rong doc theo niem mac cua cac c quan CAC DAU HIEU SIEU AM CUA PID
vung chau, nhiem trung khi au t co t cung va
noi mac t cung (viem noi mac t cung), hai voi Viem noi mac t cung
trng (viem voi trng cap), va cuoi cung en vung Day noi mac t cung hay dch
cua ca hai buong trng va phuc mac. mu tai voi Mu tui cung sau
phat trien la do tac nghen voi trng. Benh nhan Dch ln cn
thng bieu hien lam sang vi au, sot, vung chau Viem quanh buong trng
Cac buong trng ln vi nhieu nang va
nhay au va xuat tiet am ao. Co the s thay mot
b khong ro rang .
khoi vung chau .
mu tai voi hay dch tai voi
Cac dau hieu sieu am cua PID. Cac dau Voi trng ay dch co hay khong co phan am
hieu sieu am co the la bnh thng giai oan au ben trong
cua benh. Khi benh tien trien hay tr nen man tnh, Phc hp voi trng-buong trng
mot loat cac dau hieu co the xay ra (Hnh 15-53, Voi trng viem, gian dnh vao buong trng
15-54 va 15-55). Day noi mac t cung hay dch co Cac ap xe voi trng-buong trng
the bieu hien viem noi mac t cung. Co the thay Khoi hon hp a thuy vi cac vach a dang,
ro mu tui cung sau; no cha ng cac phan t co b khong eu va co phan am rai rac ben trong
phan am, giup phan biet no vi thanh dch vung
nay. Co the quan sat thay cac buong trng to vi
nhieu nang va cac b khong ro rang do viem quanh
buong trng. Tren sieu am nga bung, cac voi trng am trong ben trong voi trng bieu th cho dch tai
gian trong nh cac khoi hon hp, chu yeu dang voi, gi y rang nhiem trung la man tnh. Khi nhiem
nang ma thng khong the phan biet vi cac khoi trung nang hn, co the hnh thanh dnh quanh
phan phu khac. Tuy nhien, sieu am qua nga am buong trng, vi phc hp cua voi trng b gian,
ao nhan ra c voi trng cha ay dch nh hnh viem va buong trng viem, c goi la phc hp
ong, dang hi gap khuc, va cac thanh xac nh ro, voi trng-buong trng. Dien tien nang them se
co phan am cua no. Co the phan biet voi trng tao nen mot ap xe voi trng-buong trng, tren
gian vi mot quai ruot cha ay dch do khong co sieu am hien len nh mot khoi hop hp nhieu thuy
nhu ong. oi khi, co the can en Doppler mau e vi cac vach a dang, b khong eu va co cac
phan biet dch tai voi vi tnh mach chau phong phan am rai rac ben trong. Thng co tang am pha
len. Co the thay phan am mc o thap ben trong sau, va mot mc dch-manh vun hay kh thnh
voi trng cha ay dch do mu ( mu tai voi) va thoang co the quan sat thay ben trong khoi. Co the
oi khi co the thay mot mc dch mu. Dch phan hnh anh sieu am khong giup phan biet c vi
Hnh 15-53. dch tai voi. Hnh sieu am qua nga am ao cho thay voi trng (T) gian, cha
ay dch. mu tai voi . Hnh sieu am qua nga am ao cho thay voi trng gian (T), lap ay cac
chat co phan am mc o thap ben trong tng ng mu .
Hnh 15-54. Benh ly viem vung chau. Hnh anh sieu am

qua nga bung cho thay mot khoi ln, chu yeu phan am kem (M)
vi b khong ro net, nam pha sau trai cua t cung (U). B,
bang quang .
Hnh 15-55. Benh ly viem vung chau. Cac hnh sieu am qua nga am ao. A,Voi trng gian
cha ay dch (T) ke ben buong trng ph ai (O) B, Hnh phong ai cua buong trng vi cac b hi
khong ro rang (mui ten), va nhieu nang khong xac nh ro ngoai bien. Hnh anh ien hnh cua viem
quanh buong trng .
vi nhng khoi phan phu lanh tnh va ac tnh khac, Carcinoma

va can phai ket hp lam sang e tm ra chan oan Carcinoma cua voi trng la t gap nhat (di 1%)
chnh xac. V cac buong trng tng oi e khang trong tat ca ung th phu khoa, vi adenocarcinoma
vi nhiem trung, co the thay cac vung mo buong la loai mo hoc thng gap nhat. No thng xay ra
trng nhan dien c ben trong khoi viem qua sieu nhat phu n sau man kinh thap nien th sau,
am nga am a.109 bieu hien lam sang vi au, xuat huyet am ao, va
Ca sieu am nga bung va sieu am nga am ao mot khoi vung chau. No thng anh hng en
eu hu ch khi anh gia cac benh nhan co benh au xa, nhng co the anh hng en toan bo chieu
viem vung chau. Sieu am nga bung giup anh gia dai voi trng. Tren sieu am, carcinom voi trng
s lan rong cua benh, ngc lai sieu am nga am c mo ta nh mot khoi hnh xuc xch, dang ac
ao nhay khi phat hien voi trng gian, thay oi do hay dang nang, vi cac nhu nho ra.215,216
viem quanh buong trng, va nhng ac tnh ben
trong cua cac ap xe voi trng-buong trng.208,210 ANH GIA SIEU AM MOT KHOI U VUNG
Sieu am cung hu ch trong viec theo doi ap ng CHAU
vi ieu tr khang sinh. Cac ap xe tai voi-voi trng
co the c ieu tr bang cach choc hut va dan lu Sieu am thng c dung e anh gia mot khoi
qua am ao di hng dan cua sieu am.211,212 Dan vung chau (Bang 15-2). Khi tm thay mot khoi tren
lu bang ong c dung neu nh choc hut thc s sieu am, nen mo ta ac iem :
co mu, ngc lai, co the thc hien viec choc hut V tr (tai t cung hay ngoai t cung)
toan bo khong kem dan lu bang ong neu nh choc Kch thc
hut khong co mu.212 ng vien ben ngoai (xac nh ro, xac
benh viem vung chau man tnh, s x hoa nh khong ro, hay cac b khong eu) ;va
va dnh mc o nhieu co the lam m gii han cua o ac ben trong (dang nang, hon hp vi
cac c quan vung chau, hoa thanh mot khoi ln, phan nang la chu yeu, hon hp vi phan
xac nh khong ro. Xoan n thuan voi trng ac la chu yeu, hay dang ac).
khong thng gap, nhng no xay ra cung vi dch Noi chung, cac khoi t cung phan ln dang
tai voi man tnh.213 Benh nhan bieu hien bang s ac, oi lap vi cac khoi buong trng chu yeu la
khi au ot ngot cn au vung chau cap tnh. dang nang. Neu thay mot khoi xuat phat t t cung
dch tai voi va xoan voi trng cung a c bao th no thng la mot u co trn lanh tnh. Cac u c
cao la mot bien chng muon nhng benh nhan trn la nhng nguyen nhan thng gap cua nhng
a that voi trng .
BANG 15-1
TONG QUAT VE MO HOC CUA CAC U BUONG TRNG
Loai Xuat o V du
I. Cac u bieu mo mo em be mat 65% en 75% Cystadenoma thanh dch
(surface epithelial-stromal tumors) Cystadenoma nhay
Cystadenocarcinoma dang noi mac t cung (endometriod)
Carcinoma te bao sang (clear cell carcinoma)
U te bao chuyen tiep (trasitional cell tumor)
II. Cac u te bao mam (germ cell tumors) 15% en 20% U quai (teratoma)
U b (dermoid)
Cha trng thanh (immature)
U te bao mam cha biet hoa(dysgerminoma)
U tui noan hoang (yolk sac tumor)
III. Cac u cot gii tnh - mo em (sex cord-stromal 5% en 10% U te bao hat (granulosa cell tumor)
tumors) U te bao Sertoli - Leydig
U te bao vo va u x (thecoma va fibroma)
IV. Cac u di can (metastatic tumors) 5% en 10% Nguyen phat thuoc c quan sinh duc
T cung
Nguyen phat ngoai c quan sinh duc
Da day
ai trang
Vu
Lymphoma
BANG 15-2
CAC KHOI BUONG TRNG
Cac ac iem tren sieu am Gi y benh lanh tnh Gi y benh ac tnh
Kch thc Nho < 5cm Ln > 10cm
ng b ben ngoai Thanh mong Thanh day
Cac b xac nh ro Cac b khong xac nh ro hay khong eu
Cau truc ben trong Dang nang hoan toan Dang ac hay hon hp
Cac vach mong Cac vach day hay khong eu
Cac nhu nho ra
Cac not ac co phan am
Doppler Tr khang cao hay khong co dong mau Dong khang tr thap
Cac choi khong co mach mau Cac choi co mach mau
Cac dau hieu i kem Dch bang
Di can phuc mac
khoi dang ac phan phu, c chan oan khi CAC KHOI VUNG CHAU KHONG THUOC
thay xuat phat cua chung t t cung. oi khi, PHU KHOA
khong the xac nh nguon goc chnh xac cua khoi
bang sieu am, va MRI co the hu dung . Cac khoi u va gia u vung chau co the khong co
Phan ln cac khoi buong trng mang tnh nguon goc phu khoa. e xac lap chan oan nay,
chat chc nang. Kch thc cua khoi la quan trong, ieu quan trong la quan sat thay t cung va cac
v cac khoi di 5cm thng lanh tnh, ngc lai, buong trng tach biet khoi khoi (Hnh 15-56). ieu
cac khoi ln hn co ty le ac tnh cao hn. Nhng nay thng khong the lam c v cac khoi lam
khoi buong trng ma thuan tuy dang nang va co dch chuyen cac cau truc vung chau bnh thng.
cac b xac nh ro th gan nh luon lanh tnh. Cac Cac khoi phan phu khong phu thuoc khoa thng
khoi dang ac buong trng thng la ac tnh, nhat bat nguon t da day-ruot hay ng nieu hay
ngoai tr cac u b, cac u x, va cac u te bao chuyen co the phat trien sau phau thuat .
tiep (Brenner), la cac u thng co hnh anh sieu
am ac hieu. Nhng khoi hon hp co the lanh tnh Cac khoi vung chau sau phau thuat .
hay ac tnh va nen anh gia them ng vien cua Cac khoi sau phau thuat co the la cac ap xe, cac
thanh, cac vach va nhng not thanh. B khong khoi mau tu, cac nang bach huyet, cac u nc tieu
eu, cac vach day khong eu, cac nhu nho ra, va hay cac u thanh dch. Tren sieu am, ap xe la nhng
cac not ac co phan am se thien ve ac tnh. khoi hnh bau duc, phan am trong, vi cac thanh
Doppler mau va Doppler pho cung co the co gia day, khong eu va tang am pha sau. Co the thay
tr. Co the thay tuan hoan ben trong cac vach hay o phan am ben trong khac nhau va co the bieu
cac choi. Dong tr khang cao giup gi y chac chan hien o phan am mc o cao vi bong lng do kh.
benh lanh tnh, ngc lai, dong khang tr thap gi
y ac tnh, mac du cung co the gap benh lanh tnh.
Mac du dch bang co the i kem vi cac khoi lanh
tnh, nhng no thng thay nhieu hn rat nhieu
benh ac tnh. Dch bang ac tnh thng cha cac
manh rat nho co phan am .
Neu nghi ng mot khoi vung chau la ac tnh,
cung nen anh gia o bung e tm dau hieu cua dch
bang va di can phuc mac, benh ly tac nghen ng
nieu, hach ph ai, va di can gan va lach. Khong
thng gap di can gan va lach carcinoma buong
trng, nhng khi chung xay ra, chung thng
ngoai bien tren be mat cua gan hay lach do di can Hnh 15-56. U tao mau ngoai tuy (extramedullary
hematopoiesis). Hnh cat ngang mot phu n 44 tuoi b
phuc mac. Di can theo ng mau trong nhu mo
thalassemia khong trieu chng cho thay khoi phan am trong
gan hay lach co the xay ra giai oan tre cua (M) ben trai va tach biet vi t cung (U) va hai buong trng,
benh. la cau truc cha cac nang (mui ten). Chan oan c nh sinh
thiet qua da di hng dan cua chup cat lp ien toan .
Hnh 15-57. Sot nhau, cac hnh anh khac nhau. A, Hnh cat doc gia benh nhan 3 ngay sau khi
nao thai ieu tr cho thay khoang noi mac day (mui ten), lap ay bi cac cau truc phan am mc o khac
nhau. B, Hnh cat ngang benh nhan ra huyet lien tuc trong 2 tuan sau sanh cho thay mo nhau sot (P). C,
Hnh cat doc gia cung benh nhan (B va C, c phep cua Stephanie R.Wilson M.D, ai hoc Toronto) .
Cac khoi mau tu bieu hien mot chuoi cac dau khong the phan biet c, co the can phai sieu am
hieu sieu am, thay oi theo thi gian.217 Suot giai lai vi viec thut ra bang nc.218 Cac u ruot, ac
oan cap tnh au tien, cac khoi mau tu co phan biet la cac u lien quan en ai trang sigma-trc
am trong. Sau khi to chc hoa va tao cuc mau trang, manh trang va hoi trang co the trong giong
ong, chung tr nen co phan am cao. Vi ly giai mot khoi phan phu. Nhng u nay thng bieu
cuc mau ong, cac khoi mau tu tr nen hon hp hien dau hieu hnh bia ac trng cua mot khoi
hn, cho en cuoi cung, vi viec ly giai hoan toan, thuoc da day-ruot, bao gom mot o co phan am
chung tr lai phan am trong. Thng khong the trung tam do kh trong long ruot, c bao quanh
phan biet mot ap xe vi mot khoi mau tu tren sieu bi mot thanh day phan am kem.219 Cac ap xe lien
am, va thng can en s ket hp vi lam sang . quan en benh ly viem ng da day-ruot cung co
Cac nang bach huyet (lymphocele) vung the bieu hien nh mot khoi cua phan phu. ben
chau xay ra sau khi pha v cac kenh bach huyet phai, nguyen nhan thng gap nhat la viem ruot
trong mo, thng sau khi mo hach bach huyet vung tha hay benh Crohn, ngc lai, cac ap xe ben
chau hay ghep than. Tren sieu am, nhng nang trai thng gay ra do benh cua tui tha va gap
bach huyet co dang nang, co hnh anh tng t nh mot nhom tuoi gia hn .
hnh anh cac u nc tieu (urinoma) , la s tu nc
tieu khu tru, hay cac u thanh dch (seroma), la s Cac khoi thuoc ng nieu
tu thanh dch. Co the can phai rut dch di hng Mot than vung chau co the hien dien nh mot
dan cua sieu am e phan biet cac tnh trang nay . khoi s thay tren lam sang. ieu nay c nhan ra
de dang tren sieu am qua hnh anh dang qua than
Cac khoi thuoc ng da day ruot ien hnh va khong co mot qua than v tr bnh
Cac khoi gia u vung chau thng gap nhat la chat thng. oi khi, bang quang qua cang co the lam
phan trong trc trang, trong giong mot khoi hon vi mot nang buong trng. Khi xac nh mot khoi
hp tui cung va ai trang oan sigma-trc trang dang nang vung chau, ieu bat buoc la phai thay
cha ay dch, hien dien nh mot khoi dang nang bang quang tach biet khoi u. Cac tui tha bang
phan phu. Thng sieu am qua nga am ao co the quang cung co the giong mot khoi phan phu dang
phan biet khoi u gia vi mot khoi u that, nhng khi nang. Co the xac nh chan oan bang cach mo ta
Hnh 15-58. Viem tnh mach huyet khoi tnh mach buong trng. A, Hnh cat ngang benh nhan sot va au
bung di phai 4 ngay sau mo bat con, cho thay khoi (M) ben phai t cung hau san (UT). B, Hnh cat doc gia bung
cho thay cuc mau ong co phan am trong tnh mach buong trng phai gian (gia 2 dau thap). Ta thay cuc mau ong
lan rong vao trong tnh mach chu di (mui ten).
s thong thng vi bang quang va s thay oi

hnh anh sau khi i tieu. Nhng nieu quan oan xa
gian co the gia trong giong cac nang phan phu tren
cac hnh cat ngang; tuy nhien, nhng hnh cat doc
cho thay dang ong cua chung va s tiep noi vi
bang quang .
NHNG BENH LY VUNG CHAU THI KY

HAU SAN
Nhng benh ly trong thi ky hau san thng la hau

qua cua nhiem trung va xuat huyet. Nhng benh ly
ac trng xay ra trong giai oan hau san bao gom Hnh 15-59. Tu mau nap bang quang. Hnh cat doc
viem noi mac t cung, sot nhau (retained products gia benh nhan sot va au ha v vao ngay th 8 sau mo
of conception) va viem tnh mach huyet khoi bat con, cho thay khoi mau tu (H) gia bang quang va seo
mo bat con (mui ten). U, t cung. (c phep cua
buong trng. Viem noi mac t cung thng gap Stephanie R.Wilson M.D, ai hoc Toronto.
sau mo bat con nhieu hn khi sanh qua nga am
ao. No thng xay ra cac benh nhan co cuoc Viem huyet khoi tnh mach buong trng
sanh keo dai hay v oi sm hay ngi sot nhau. Huyet khoi tnh mach buong trng khi sanh hay
Nguon sinh vat thng gap nhat la vi khuan bnh viem huyet khoi tnh mach la mot tnh trang khong
thng am ao. Ve lam sang, co cn au vung thng gap nhng tiem an s e doa en tnh
chau hoac sot khong giai thch c . mang. (Hnh 15-58). Cac benh nhan bieu hien sot,
au bung di, va s thay mot khoi, thng 48 en
Sot nhau 96 gi sau sanh. Nguyen nhan c ban la s tac tnh
Mo nhau sot lai sau khi sanh co the gay ra xuat mach va viec lan rong nhiem trung do vi trung t
huyet hau san th phat hay co the ong vai tro nh viem noi mac t cung. Tnh mach buong trng phai
nguon phat sinh ra nhiem trung. Tren sieu am, mot co lien quan en 90% trng hp. Dong tnh mach
khoi co phan am ben trong khoang noi mac (Hnh chay ngc lai xay ra tnh mach buong trng trai
15-57, A) cung co manh me cho chan oan suot thi ky sinh san, bao ve ben nay khoi s lan
nay.220,221 Co the gap mot khoi hon hp, nhng tran cua vi khuan t t cung.35 Co the chan oan
cung co the do mau cuc hay chat hoai t hay tnh trang nay bang sieu am, CT hay MRI.222,223
nhiem trung gay ra ma khong co s hien dien cua Sieu am co the xac nh mot khoi viem pha ngoai
mo nhau.221 oi khi, co the xac nh mo nhau ro t cung va pha trc c that lng chau. Co the
rang (Hnh 15-57, B va C).
thay tnh mach buong trng nh mot cau truc ong, THAM KHAO
phan am trong, hng ve pha au t khoi va cha Giai phau bnh thng vung chau
1. Williams PL, Warwick R. Grays Anatomy. 37th ed. Edinburgh:
cuc mau ong co phan am. Cuc mau ong thng Churchill Livingstone: 1989.
anh hng en oan au tien cua tnh mach buong 2. Jones HW III, Wentz AC, Burnett LS. Novak's Textbook of
trng phai va thng c xac nh tren sieu am la Gynecology: 11th ed. Baltimore: Williams & Wilkins: 1988.
tai cho noi cua tnh mach buong trng phai vi tnh Ky thuat
3. Cnllinan JA, Fleischer AC, Kepple DM et al. Sonohysteroraphy: a
mach chu di, thnh thoang lan vao trong tnh technique for endometrial evaluation. RadioGraphics 1995:15:501-
mach chu di. Cung co the thay cuc mau ong 514.
4. Mendelson EB. Bolim-Velez M. Joseph N et al. Gynecologic
tnh mach chu di.224 Hnh Doppler duplex co the imaging: comparison of transabdominal and transvaginal
bieu hien khong co dong mau trong cac tnh mach sonography. Radiology 1988:166:321-324.
nay.225 Phan ln benh nhan ap ng vi viec ieu 5. Lande [M. Hill MC, Cosco FE el al. Adnexal and cul-de-sac abnor-
malities: transvaginal sonography. Radiology- 1988: 166:325-332.
tr khang ong va khang sinh, va sieu am theo doi 6. Leihman AJ. Kruse B. McSweeney MB. Transvaginal sonography:
co the thay s phan giai cuc mau ong va dong comparison with transabdominal sonography in the diagnosis of
mau bnh thng tren hnh Doppler anh oi. pelvic masses. AJR 1988:151:89-92.
7. Tester FN, Schiller VL. Perrella RR et al. Transabdominal
versus endovaginal pelvic sonography: prospective study. Radiology
Nhng bien chng cua mo bat con 1989:170:553-556.
8. Coleman BC, Arger PH. Grumbach K et al. Transvaginal and trans-
V tr cat ngang oan di t cung thng c abdominal sonography: prospective comparison. Radiology 1988;
dung trong mo bat con. Tren sieu am, co the xac 168:639-643.
9. Andolf E, Jorgensen C. A prospective comparison of transabdominal
nh v tr vet mo la mot vung hnh oval, oi xng,
and transvaginal ultrasound with surgical findings in gynecologic
phan am kem so vi c t cung, nam gia thanh disease. J Ultrasound Med 1990;9:71-75.
sau cua bang quang va oan di t cung.226 oi 10. DiSantis DJ. Scatarige JC, Kemp G et al. A prospective evaluation
of transvaginal sonography for detection of ovarian disease. AJR
khi co the nhan ra cac moi ch ben trong cho mo 1993;l6l:9l -94.
nh cac om nho co phan am mc o cao . T cung
Nhng khoi mau tu co the hnh thanh do xuat 11. Sample WF. Lippe BM. Cyepes MT. Gray-scale ultrasonography
huyet tai v tr vet mo (Tu mau nap-bang quang) of the normal female pelvis. Radiology-1977:125:477-483.
12. Orsini LF, Salardi S, Pilu G et al. Pelvic organs in premenarcheal
hay ben trong vung trc bang quang (tu mau di girls: real-time ultrasonography. Radiology 1984:153:113-116.
can). Cac khoi mau tu nap-bang quang (bladder- 13. Nussbaum AR, Sanders RC, Jones MD. Neonatal uterine morpho-
logy as seen on real-time US. Radiology 1986:160:641-643.
flap) co the c chan oan bang sieu am khi co 14. Siegel MJ. Pediatric gynecologic sonography. Radiology 1991;
mot khoi phan am hon hp hay trong, ng knh 179:593-600.
hn 2cm, nam ke seo mo va gia oan di t 15. Platt JF, Bree RL, Davidson D. Ultrasound of the normal nongravid
uterus:correlation with gross and histopathology. J Clin Ultrasound
cung va thanh sau bang quang (Hnh 15-59). o 1990:18:15-19.
phan am thay oi tuy thuoc vao so lng cac 16. Miller El, Thomas RH, Lines P. The atrophic postmenopausal
thanh phan ben trong khoi mau tu.217 S hien dien uterus. J Clin Ultrasound 1977;5:261-263.
17. Fleischer AC, Kalemeris GC, Machin JE et al. Sonograpllic
cua kh ben trong khoi gi y nhieu en mot khoi depiction of normal and abnormal endometrium with histopatho-
mau tu nhiem trung. Cac khoi mau tu di can logic correlation . J Ultrasound Med 1986;5:445-452.
18. Farrer-Brown G, Beilby JOW, Tarbit MH. The blood supply of the
nam ngoai phuc mac, trong vung trc bang quang uterus. 2. venous pattern. Br J Obstet Gynecol Comm 1970,77:682-
va tao ra do s pha v cac mach mau thng v 689.
di hoac cac nhanh cua chung khi mo bat con hay 19. DuBose TJ, Hill LW, Hennigan HW Jr et al. Sonography of arcuate
uterine blood vessels. J Ultrasound Med 1985;4:229-233.
chan thng khi sanh qua nga am ao.229 Tren sieu 20. Occhipinti K, Kutcher R, Rosenblatt R. Sonographic appearance
am quan sat thay mot khoi hon hp hoac dang and significance of arcuate artery calcification. J Ultrasound Med
1991:10:97-100.
nang pha trc bang quang. Thng can en
21. Atri M, de Stempel J, Senternian MK et al. Diffuse peripheral
nhng au do tan so cao, tieu iem ngan e nhan uterine calcification (manifestation of Monckeberg's arterio-
ra khoi nong. ieu quan trong la phai xac nh sclerosis) detected by ultrasonography. J Clin Ultrasound 1992;
20:211-216.
c thang bung e phan biet khoi mau tu do vet 22. Burks DD, Stainken BF, Burkhard TK et al. Uterine inner myome-
thng nong, nam pha trc c thang bung, vi trial echogenic foci: relationship to prior dilatation and curettage
and endocervical biopsy. J Ultrasound Med 199UO:487-492.
khoi mau tu di can, nam sau c thang bung.228
23. Callen PW, DeMartini WJ. Filly RA. The central uterine cavity
Co the thay cac khoi mau tu nap-bang quang va echo: a useful anatomic sign in the ultrasonographic evaluation of
di can tren cung mot benh nhan; tuy nhien, the female pelvis. Radiology 1979;131:187-190.
24. Fleischer AC, Kalemeris CC, Fntman SS. Sonographic depiction of
chung co nguon goc xuat huyet khac nhau va nen the endometrium during nornial cycles. J Ultrasound Med Biol
ieu tr chung nh cac tnh trang rieng biet . 1986:12:271-277.
25. Forresi IS, Elvaderani MK, Muilenburg MI et al. Cyclic endo- in the diagnosis of diffuse adenomyosis. Fertil Steri1 992:58:
metrial changes: US assessment with histologic correlation. 94-97.
Radiology-1988:167:233-237. 51. Reinhold C, Atri M. Mellio A et al. Diffuse uterine adeno-
26. Pennes DR. Bowerman RA, Silver TM., Congenital uterine myosis: morphologic criteria and diagnostic accuracy of endo-
anomalies and associated pregnancies: findings and pitfalls of vaginal sonography. Radiology 1995:197:609-614.
sonographic diagnosis. J Ultrasound Med 1985:4:531 -538. 52. Eedele L, Bianchi S, Dorta M et al. Transvaginal ultrasonography
27. Fried AM. OliffM, Wilson EA et al. Uterine anomalies associated in the differential diagnosis of adenomyoma versus leiomyoma.
with renal agenesis: role of gray scale ultrasonography. AJR 1978; Am J Obstet Gynecol 1992:167:603-606.
131:973-975. 53. Togashi K, Ozasa EL Konishi I et al. Enlarged uterus: differen-
28. Wiersnia AF, Peterson LF, Justema F.I. Uterine anomalies tiation between adenomyosis and leiomyoma with MR imaging.
associated with unilateral renal agenesis. Obstet Gynecol 1976; Radiology 1989:171:531-534.
47:654-657. 54. Asclier SM. Arnold El.. Patt BEI et al. Adenomyosis: prospective
29. Nicolini U. Bellotti M. Bonazzi B et al. Can ultrasound be used to comparison of MR imaging and transvaginal sonography.
screen uterine malformations? Fertil Steril 1987:47:89-93. Radiology-1994:190:803-806.
30. Voder 1C. Diagnosis of uterine anomalies: relative accuracy of 55. Reinliold G. McCarthy S. Bret PM et al. Diffuse adenomyosis:
MR imaging, endovaginal sonography. and hysterosalpinggraphy. comparison of endovaginal ES and MR imaging with histopatho-
Radiology 1992:185:343. logic correlation. Radiology 1996:199:151-158.
31. Router KF, Daly DC. Cohen SM. Septate versus bicornuate uteri: 56. Torres WE, Stones PJ Jr. Thames EM. Ultrasound appearance of
errors in imaging diagnosis. Radiology 1989:172:749-752 pelvic arteriovenous malformation. J Clin Ultrasound 1979:7: 383-
32. Pellerilo JS, McCarthy SM, Doyle MB et al. Diagnosis of uterine 385.
anomalies: relative accuracy of MR imaging, endovaginal 57. Musa AA, Hata T, Hata K et al. Pelvic arteriovenous malfor-
sonography and hysterosalpingography. Radiology 1992:183: mation diagnosed by color flow Doppler imaging. AJR 1989: 152:
795-800. 1311-1312.
33. Viscomi GN, Gonzalez R. Taylor KJW. Ultrasound detection of 58. Huang M, Muradali D, Thurston WA et al. Uterine arteriovenous
uterine abnormalities after diethylstilbestrol (DES) exposure. malformations (AVMs): ultrasound and Doppler features with
Radiology-1980;136:733-735. MRI correlation. Radiology-1997; in press.
34. Lev-Toaff AS, Toaff ME, Friedman AC. Endovaginal sonographic 59. Mendelson EB, Bohm-Velez M, Joseph N et a1. Endometrial
appearance of a DES uterus. J Ultrasound Med 1990:9:661-664. abnormalities: evaluation with transvaginal sonography. AJR
35. Kurman RJ. Blaustein's Radiology of the Female Genital Tract. 1988:150:139-142.
4th ed. New York: Springer-Verlag: 1994. 60. Varncr E. Sparks JM, Cameron CD et al. Transvaginal sono-
36. Smith JP, Weiscr EB, Karnei RE Jr et al. Ultrasonography of graphy of the endometrium in postmenopausal women. Obstet
rapidly growing uterine leiomyomata associated with anovulatory Gynecol 1991;78:195-199,
cycles. Radiology-1980:134:713-716. 61. Granberg S, Wickland M, Karlsson B el al. Endomelrial thickness
37. Eev-Toaff AS. Coleman BG, Arger PH et al. Leiomyomas in as measured by endovaginal ultrasonography for identifying
pregnancy: sonographic stndy. Radiology 1987;164:375-380. endometrial abnormalily Am J Obstet Gynecol 1991;164:47-52.
38. Dilts PV Jr. Hopkins MP. Ghang AE et al. Rapid growth of 62. Osrners R, Volkson M. Schauer A. Vaginosonography for early
leiomyoma in patient receiving tamoxifen. Am J Obstel Gynecol detection of endometrial carcinoma Lancet 1990; 335:1569-1571.
1992:166:167-168. 63. Nasri MN, Shepherd JH, Setchell ME et al. The role of vaginal
39. Gross BH. Silver TM. Jaffe Mil. Sonographic features of uterine scan in measurement of endometrial thickness in postmenopausal
leiomymas: analysis of 41 proven cases. J Ultrasound Med women. Br J Obstel Gynaecol 1991;98:470-475.
1983:2:401-406. 64. Goldstein SR, Nachtigall M, Snyder JR et al. Endometrial assess-
40. Kliewer MA. Hertzbcrg BS. George PY el al. Acoustic shadowing ment by vaginal ultrasonography before endometrial sampling in
from uterine leiomyomas: sonographic-pathologic correlation. patients with postmenopausal bleeding.Am J Obstet Gynecol 1990;
Radiology-1995:T 96:99-102. 163:119-123.
41. Baltarowich OH, Kurtz AB, Pennell RG et al. Pitfalls in the 65. Karlsson B, Granherg S. Wikland M et al. Transvaginal ultrasono-
sonographic diagnosis of uterine fibroids. AJR 1988:151:725-728. graphy of the women with postmenopausal bleeding: a Nordic
42. Moore I., Wilson S, Rosen B. Giant hydropic uterine leiomyorna multicenter study. Am J Obstet Gynecol 1995: 172:1488-1494.
in pregnancy: unusual sonographic and Doppler appearance. 66. Shiplev CE 111. Simmons GE. Melson GH. Comparison of trans-
J Ultrasound Med 1994:13:416-418. vaginal sonography with endometrial biopsy in asymptomatic
43. Eedele E, Bianclii S, Dorta M et al. Transvaginal nitrasonography postmenopansal women. J Ultrasound Med 1994;13:99-104.
versus hysteroscopy in the diagnosis of uterine submucous 67. Lin MC, Gosink BB. Wolf Sl et al. Endomelrial thickness after
myomas. Obstet Gynecol 1991:77:745-748. menopause: effect of hormone replacement. Radiology 1991:
44. Karasick S. Eev-Toaff AS, Toaff ME. Imaging of uterine leio- 180:427-432.
myomas. MR 1992:158:799-805. 68. Aleem E. Predanic M, Calame K et al. Transvaginal color and
45. Dodd GD III, Budzik BE Jr. Lipomatous uterine tumors: dia- pulsed Doppler sonography of the endometrium: a possible role in
gnosis by ultrasound, CT and MR. Comput Assist Tomogr 1990: reducing the number of dilatation and curetlage procedures. J
14:629-632. Ultrasound Med 1995:14:1.39-14.5.
46. Serafini G, Martinoli G. Qnadri P el al. Lipomatons tumors of the 69. Eevine D. Gosink BB. Johnson LA. Change in endometrial thick-
uterus: ultrasonographic findings in 11 cases. J Ultrasound Med ness in postmenopausal women undergoing hormone replacement
1996:16:195-199. therapy. Radiology 1995:197:603-608.
47. Herlzberg BS. Kliewer A. George P et al. Lipomatous uterine 70. Lewit N. Thaler 1, Rottem S. The ulerus: a new look with trans-
masses: potential to mimic ovarian dermoids on endovaginal vaginal sonography. J Clin Ultrasound 1990:18:331-336.
sonography. J Ultrasound Med 1995:14:689-692. 71. Breckenridge JW. Kurtz AB. Rilchie WCM el al. Postmenopausal
48. Siedler I), J.aing EG. Jeffrey RB Jr et al. Uterine adenomyosis: a uterine fluid collection: indicalor of carcinoma. AJR 1982: 139:
difficult sonographic diagnosis. J Ultrasound Med 1987: 6: 529-534.
345-349. 72. McCarthy KA. Hall DA. Kopans DB et al. Postmenopausal endo-
49. Bohlman ME. Ensor BE. Sanders RG. Sonographic findings in metrial fluid collections: always an indicator of malignancy? J
adenomyosis of the uterus. AJR 1987:148:765-766. Ultrasound Med 1986:5:647-649.
50. Eedele E. Bianchi S. Dorta M et al. Transvaginal ultrasonography 73. Goldstein SR. Postmenopausal endometrial fluid collections
revisited: look at the doughnut rather than the hole. Obstet 96. Kurjak A, Shalan H, Sosic A et al. Endometrial carcinoma in post-
Gynecol 1994:83:738-740. menopausal women: evaluation by transvaginal color Doppler
74. Wilson DA. Slacy TM, Smith El. Ultrasound diagnosis of hydro- ultrasonography. Am J Obstet Gynecol 1993; 169:1597-1603.
colpos and hydrometrocolpos. Radiology 1978:128:451-454. 97. Sheth S, Hamper UM, McCollum ME et al. Endometrial blood
75. Scott WW .|r. Rosensliein NB. Siegelinan SS et al. Tlie obstructed flow analysis in postmenopausal women: can it help differentiate
uterus. Radiology 1981:141:767-770. benign from malignant causes of endometrial thickening?
76. Slieth S, Hamper VM. Kin-man R.I. Thickened endometriuin in the Radiology 1995;195:661-665.
postmenopausal woman: sonographic-pathologic correlation. 98. Fleischer AC, Dudley BS, Entman SS et al. Myometrial invasion
Radiology 1993:187:135-139. by endometrial carcinoma: sonographic assessment. Radiology
77. Hulka CA. Hall DA, McCarthy K et al. Endometrial polyps hyper- 1987:162:307-310.
plasia and carcinoma in postmenopausal women: differentiation 99. Cacciatore B, Lehtovirta P, Wahlstrom T et al. Preoperative sono-
with endovaginal sonography. Radiology- 1994: 191:755-758. graphic evaluation of endometrial cancer. Am J Obstet Gynecol
78. Atri M. Nazamia S. Aldis AE et al. Transvaginal I'S appearance of 1989:160:133-137.
endometrial abnormalities. Radiographics 1994:14:483-492. 100. Gordon AN, Fleischer AC, Reed GW. Depth of myometrial
79. Choo YC, Mak KG, Hsu C et al Postmenopausal uterine bleeding invasion in endometrial cancer: preoperative assessment by trans-
of nonorganic cause. Obstet Gynecol 1985;66:225-228. vaginal ultrasonography. Gynecol Oncol 1990:39:321-327.
80. Kupfer MC, Schiller VL, Hansen GC et al. Transvaginal sono- 101. DelMaschio A, Vanzulli A, Sironi S et al. Estimating the depth of
graphic evaluation of endometrial polyps. J Ultrasound Med 1994; myometrial involvement by endometrial carcinoma: efficacy of
13:535-539. transvaginal sonography vs MR imaging. AJR 1993:160:533-538.
81. Parsons AK. Lense JJ. Sonohysterography for endometrial abnor- 102. Yamashita Y, Mizutani H, Torashima M et al. Assessment of
malities: preliminary results. J Clin Ultrasound 1993;21:87-95. myometrial invasion by endometrial carcinoma: transvaginal sono-
82. Gaucherand P, Piacenza JM. Salle B et al. Sonohysterography graphy vs contrast-enhanced MR imaging. AJR 1993; 161:595-599.
of the uterine cavity: preliminary investigations. J Clin 103. Wachsberg RH, Kurtz AB. Gas within the endometrial cavity at
Ultrasound 1995:23:339-348. postpartum US: a normal finding after spontaneous vaginal
83. Dubinsky TJ, Parvey HR, Gormaz G et al. Transvaginal hystero- delivery. Radiology 1992;183:431-433.
sonography in the evaluation of small endoluminal masses. J 104 Fedele I. Bianchi S, Dorta M et al. Intrauterine adhesions:
Ultrasound Med 1995:14:1-6. detection with transvaginal US. Radiology 1996:199:757-759.
84. Karlsson B, Granberg S, Hellberg P et al. Comparative study of 105 Callen PW, Filly RA, Munyer TP. Intrauterine contraceptive
transvaginal sonography and hysteroscopy for the detection of devices: evaluation by sonography. AJR 1980:135:797-800.
pathologic endometrial lesions in women with postmenopausal 106. Fogel SR, Slasky BS. Sonography of nabothian cysts. AJR 1982:
bleeding. J Ultrasound Med 1994;13:757-762. 138:927-930.
85. Malfetano JH. Tamoxifen-associated endometrial carcinoma in Am ao
postmenopausal breast cancer patients . Gynecol Oncol 1990;39: 107. McCarthy S, Taylor KJW. Sonography of vaginal masses. AJR
82-84. 1983;140:1005-1008.
86. Kedar RP, Bourne TH, Powles TJ et al. Effects of tamoxifen on 108. Schoenfeld A, Levavi H, Hirsch M et al. Transvaginal sonography
uterus and ovaries of postmenopausal women in a randomised in postmenopausal women. J Clin Ultrasound 1990; 18:350-358.
breast cancer prevention trial. Lancet 1994; 343:1318-1321.
Ngach trc trang-t cung (tui cung sau)
87. Lahti E, Blanco G, Kauppila A et al. Endometrial changes in post-
109. Mendelson EB, Bohm-Velez M, Neiman HE et al. Transvaginal
menopausal breast cancer patients receiving tamoxifen. Obstet
sonography in gynecologic imaging. Semin Ultrasound CT MR
Gynecol 1993;81:660-664. .
1988:9:102-121.
88. Cohen I, Rosen DJD, Tepper R et al. Ultrasonographic evaluation
110. Davis JA, Gosink BB. Fluid in the female pelvis: cyclic patterns. J
of the endometrium and correlation with endometrial sampling in
Ultrasound Med 1986;5:75-79.
postmenopausal patients treated with tamoxifen. J Ultrasound Med
111. Koninckx PR, Renaer M, Brosens IA. Origin of peritoneal fluid in
1993;5:275-280.
women: an ovarian exudation product. Br J Obstet Gynaecol 1980;
89. Hulka CA, Hall DA. Endometrial abnormalities associated with
87:177-183.
tamoxifen therapy for breast cancer: sonographic and pathologic
112. Jeffrey RB, Laing FC. Echogenic clot: a useful sign of pelvic
correlation. AJR 1993;160:809-812.
hemoperitoneum. Radiology 1982:145:139-141.
90. Goldstein SR. Unusual ultrasonographic appearance of the uterus
113. Nyberg DA, Hughes M, Mack IA et al. Extrauterine findings of
in patients receiving tamoxifen. Am J Obstet Gynecol 1994:170:
ectopic pregnancy at transvaginal US : importance of echogenic
447-451.
fluid. Radiology-1991;178:823-826.
91. Bourne TH. Campbell S, Steer CV et al. Detection of endometrial
cancer by transvaginal ultrasonography with color flow imaging Buong trng
and blood flow analysis: a preliminary report. Gynecol Oncol 114. Cohen HE, Shapiro MA, Mandel FS et al. Normal ovaries in neo-
1991;40:253-259. nates and infants: a sonographic study of 77 patients 1 day to 24
92. Weiner Z, Beck D, Rottem S et al. Uterine artery flow velocity months old. AJR 1993:160:583-586.
waveforms and color flow imaging in women with perimenopausal 115. Cohen HL, Eisenberg P, Mandel F et al. Ovarian cysts are com-
and postmenopausal bleeding: correlation to endometrial histopa- mon in premenarchal girls: a sonographic study of 101 children 2-
thology. Acta Obstet Gynecol Scand 1993;72:162-166. 12 years old. AJR 1992;159:89-91.
93. Chan FY, Chau MT, Pun TC et al. Limitations of transvaginal 116 Cohen HE Tice HM, Mandel FS. Ovarian volumes measured by
sonography and color Doppler imaging in the differentiation of US: bigger than we think. Radiology-1990:177:189-192.
endometrial carcinoma from benign lesions. J Ultrasound Med 117. van Nagel JR Jr, Higgins RV, Donaldson ES et al. Transvaginal
1994,13:623-628. sonography as a screening method for ovarian cancer. Cancer
94. Carter JR, Eau M. Saltzman AK et al. Gray scale and color flow 1990;65:573-577.
Doppler characterization of uterine tumors.J Ultrasound Med 1994; 118. Brandt KR, Thurmond AS, McCarthy JE. Focal calcifications in
13:835-840. otherwise ultrasonographically normal ovaries. Radiology 1996:
95. Sladkevicius P., Valentin E, Marsal K. Endometrial thickness and 198: 415-417.
Doppler velocimetry of the uterine arteries as discriminators of 119 Goswamy RK. Campbell S, Royston JP et al. Ovarian size in post-
endometrial status in women with postmenopausal bleeding: a menopausal women. Br J Obstet Gynaecol 1988;95:795-801.
comparative study. Am J Obstet Gynecol 1994;171:722-728. 120. Granberg S, Wickland M. A comparison between ultrasound and
gynecologic examination for detection of enlarged ovaries in a 146. Sommerville M, Grimes DA, Koonings PP et al. Ovarian neo-
group of women at risk for ovarian carcinoma. J Ultrasound Med plasms and the risk of adnexal torsion. Am J Obstet Gynecol
1988:7:59-64. 1991;164:577-578.
121. Andolf E, Jorgensen C, Svalenins E et al. Ultrasound mea- 147. Graif M, Itzchak Y. Sonographic evaluation of ovarian torsion in
surement of the ovarian volume. Acta Obstet Gynecol Scand 1987: childhood and adolescence. AJR 1988:150:647-649.
66: 387-389. 148. Fleischer AC, Stein SM, Cullinan JA et al. Color Doppler sono-
122. Hall DA, McCarthy KA, Kopans DB. Sonographic visualization of graphy of adnexal torsion. J Ultrasound Med 1995;14:523-528.
the normal postmenopausal ovary. J Ultrasound Med 1986:5:9-11. 149. Stark JE, Siegel MJ. Ovarian torsion in prepubertal and pubertal
123. Fleischer AC, McKee MS. Gordon AN et al. Transvaginal sono- girls: sonographic findings. AJR 1994;163:1479-1482.
graphy of postmenopausal o varies with pathologic correlation. 150. Rosado WM, Trambert MA, Gosink BR et al. Adnexal torsion:
J Ultrasound Med 1990:9:637-644. diagnosis by using Doppler sonography. AJR 1992;159:1251-1253.
124. Wolf SI, Gosink BB, Feldesman MR et al. Prevalence of simple 151. Kapadia R, Sternhill V, Schwartz E. Massive edema of the ovary.
adnexal cysts in postmenopausal women. Radiology- 1991;180: J Clin Ultrasound 1982;10:469-471.
65-71. 152. Lee AR, Kim KH, Lee BH et al. Massive edema of the ovary:
125. Levine D, Gosink BB, Wolf SI et al. Simple adnexal cysts: the imaging findings. AJR 1993;161:343-344.
natural history in postmenopausal women . Radiology 1992- 184: 153. Hill LM, Pelekanos M, Kanbour A. Massive edema of an ovary
653-659. previously fixed to the pelvic side wall.J Ultrasound Med 1993;12:
126. Hall DA, McCarthy KA. The significance of the postmenopausal 629-632.
simple adnexal cyst. J Ultrasound Med 1986-5:503-505. 154. Wingo PA, Tong T, Bolden S. Cancer statistics, 1995. CA Cancer
127. Rulin MC, Preston AL. Adnexal masses in postmenopausal J Clin 1995;45:8-30.
women. Obstet Gynecol 1987:70:578-581. 155. Kerlikowske K, Brown JS, Grady DG. Should women with fami-
128. Andolf E, Jorgensen C. Simple adnexal cysts diagnosed by ultra- lial ovarian cancer undergo prophylactic oophorectomy? Obstet
sound in postmenopausal women. J Clin Ultrasound 1988:16:301- Gynecol 1992;80:700-707.
303. 156. Lynch HT, Watson P, Lynch JF et al. Hereditary ovarian cancer:
129. Goldstein SR, Subramanyam B, Snyder JR et al. The postmeno- heterogeneity in age at onset. Cancer 1993;71;573-581.
pausal cystic adnexal mass: the potential role of ultrasound in 157. Einhorn N, Sjovall K, Knapp RC et al. Prospective evaluation of
conservative management. Obstet Gynecol 1989-73:8-10. serum CA125 levels for early detection of ovarian cancer. Obstet
130. Hall DA. Sonographic appearance of the normal ovary, of poly- Gynecol 1992;80:14-18.
cystic ovary disease, and of functional ovarian cysts. Semin 158. Jacobs I, Davies AP, Bridges J et al. Prevalence screening for
Ultrasound 1983:4:149-165. ovarian cancer in postmenopausal women by CA 125 measure-
131. Baltarowich OH, Kurtz AB, Pasto ME et al.The spectrum of sono- ment and ultrasonography. BMJ 1993;306:1030-1034.
graphic findings in hemorrhagic ovarian cysts. AJR 1987:148: 159. Campbell S, Bhan V, Royston P et al. Transabdominal ultrasound
901-905. screening for early ovarian cancer. BMJ 1989:299:1363-1367.
132. Yoffe N, Bronshtein M, Brandes J et al. Hemorrhagic ovarian cyst 160. DePriest PD, van Nagell JR Jr, Gallion HH et al. Ovarian cancer
detection by transvaginal sonography: the great imitator. Gynecol screening in asymptomatic postmenopausal women. Gynecol
Endocrinol 1991:5:123-129. Oncol 1993;51:205-209.
133. Phillips HE, McGahan JP.Ovarian remnant syndrome. Radiology 161. Bast RC Jr, Klug TL, St. John E et al. A radioimmunoassay
1982;142:487-488. using a monoclonal antibody to monitor the course of epithelial
134. Athey PA, Cooper NB. Sonographic features of parovarian cysts. ovarian cancer. N Engl J Med 1983;309:883-887.
AJR 1985:144:83-86. 162. Jacobs I, Bast RC Jr. The CA 125 tumor-associated antigen: a
135. Alpern MB, Sandier MA, Madrazo BL. Sonographic features of review of the literature. Hum Reprod 1989;4:1-12.
parovarian cysts and their complications. AJR 1984-143:157-160. 163. Taylor KJW, Schwartz PE. Screening for early ovarian cancer.
136. Kim JS, Woo SK, Suh SJ et al. Sonographic diagnosis of para- Radiology 1994;192:1-10.
ovarian cysts: value of detecting a separate ipsilateral ovary. AJR 164. Kurjak A, Shalan H, Kupesic S et al. An attempt to screen asymp-
1995:164:1441-1444. tomatic women for ovarian and endometrial cancer with trans-
137. Hotter FA, Kozakewich H, Colodny A et al. Peritoneal inclusion vaginal color and pulsed Doppler sonography. J Ultrasound Med
cysts: ovarian fluid in peritoneal adhesions. Radiology-1988:169: 1994;13:295-301.
189-191. 165. Bourne TH, Gampbell S, Reynolds KM et al. Screening for early
138. Sohaey R, Gardner TL, Woodward PJ et al. Sonographic dia- familial ovarian cancer with transvaginal ultrasonography and
gnosis of peritoneal inclusion cysts. J Ultrasound Med 1995:14: colour blood flow imaging. BMJ 1993:306:1025-1029.
913-917. 166. Karlan BY, Raffel LJ, Crvenkovic G et al. A multidisciplinary
139. Friedman H, Vogelzang RL, Mendelson EB et al. Endometriosis approach to the early detection of ovarian carcinoma: rationale,
detection by US with laparoscopic correlation. Radiology-1985: protocol design, and early results. Am J Obstet Gynecol 1993;169:
157:217-220. 494-501.
140. Kupfer MC, Schwimmer SR, Lebovic J. Transvaginal sonographic 167. Weiner Z, Beck D, Shteiner M et al. Screening for ovarian cancer
appearance of endometriomata: spectrum of findings.J Ultrasound in women with breast cancer with transvaginal sonography and
Med 1992; 11:129-133. color flow imaging. . J Ultrasound Med 1993;12:387-393.
141. Athey PA, Diment DD. The spectrum of sonographic findings in 168. Moyle JW, Rochester D, Sider L et al. Sonography of ovarian
endometriomas. J Ultrasound Med 1989:8:487-491. tumors: predictability of tumor type. AJR 1983:141:985-991.
142. Yeh HC, Futterweit W, Thornton JC. Polycystic ovarian disease: 169. Cranherg S. Wickland M. Jansson 1. Macroscopic characterization
US features in 104 patients. Radiology 1987-163-111-116. of ovarian tumors and the relation to the histologic diagnosis:
143. Hann LE, Hall DA, McArdle CR et al. Polycystic ovarian disease: criteria to be used for ultrasound evaluation. Gynecol Oncol 1989:
sonographic spectrum. Radiology 1984; 150:531-534. 35:139-144.
144. Pache TD, Wladimiroff ]W, Hop WCJ et al. How to discriminate 170. P'inkler N.L Benacerraf B. Lavin PT et al. Comparison of serum
between normal and polycystic ovaries: transvaginal US study. CA 125 , clinical impression, and ultrasound in the preoperative
Radiology 1992:183:421-423. evaluation of ovarian masses. Obstet Gynecol.1988:72:659-664.
145. Ardaens Y, Robert Y, Lemaitre L et al. Polycystic ovarian dis- 171. Sassone AM, Timor-Tritsch IE. Artner A et al. Transvaginal sono-
ease: contribution of vaginal endosonography and reassessment graphic characterization of ovarian disease: evaluation of a new
of ultrasonic diagnosis. Fertil Steril 1991:55:1062-1068. scoring system to predict ovarian malignancy. Obstet Gynecol
1991 :78:70-76. cell tumors of the ovary: radiologic-pathologic correlation.

172. DePriest PD, van Nagell JR Jr, Callion HH et al. Ovarian Radiographics 1990:10:715-724.
cancer screening in asymptomatic postmenopausal women. 195. Quinn SF, Erickson S, Black WC. Cystic ovarian teratomas:
Gynecol Oncol 1993;51:205-209. the sonographic appearance of the dermoid plug. Radiology
173. Folkman J. Watson K, Ingber D et al. Induction of angiogenesis 1985:155:477-478.
during the transition from hyperplasia to neoplasia. Nature 1989: 196. Sheth S, Fislunan EK. Buck JL et al. The variable sonographic
339:58-61. appearances of ovarian teratomas: correlation with CT AJR
174. Bourne T. Campbcll S, Steer C et al. Transvaginal color flow 1988: 151:331-334.
imaging: a possible new screening technique for ovarian cancer. 197. Guttman PI1 Jr. In search of the elusive benign cystic ovarian
Br Med J 1989:399:1367-1370. teratoma: application of the ultrasound "tip of the iceberg" sign.
175. Kurjak A. Zaiud I, Alfirevic Z. Evaluation of adnexal masses J Clin Ultrasound 1977;5:403-406.
with transvaginal color ultrasound. J Ultrasound Med 1991:10:295- 198. Bronshlein M. Yoffe N. Brandes JM et al. Hair as a sonographic
297. marker of ovarian teratomas: improved identification using
176. Weiner Z, Thaler I, Beck D et al. Differentiating malignant from transvaginal sonography and simulation model. J Clin Ultrasound
benign ovarian tumors with transvaginal color flow imaging. 1991:19:351-355
Obstet Gynecol 1992;79:159-162. 199. Malde MM. Kedar RP, Chadha D et al. Dermoid mesh: a sono-
177. Fleischer AC, Rodgers WH, Rao BK et al. Assessment of ovarian graphic sign of ovarian teratoma. Letter AJR 1992:159:1349-1350.
tumor vascularity with transvaginal color Doppler sonography. J 200. O'Malley BP, Richmond H. Struma ovarii. J Ultrasound Med
Ultrasound Med 1991;10:563-568. 1982:1:177-178.
178. Hamper UM, Sheth S, Abbas FM et al. Transvaginal color 201. Tanaka YO. Kurosaki Y. Msliida M et al. Ovarian dysgerminoma:
Doppler sonography of adne-xal masses: differences in blood flow MR and CT appearance. J Comput Assist Tomogr 1994:18:443-
impedance in benign and malignant lesions. AJR 1993; 160:1225- 448.
1228. 202. Kirn SI 1. Kang SR. Ovarian dysgerminoma: Color Doppler ultra-
179. Tekay A, Jouppila P. Validity of pulsatility and resistance indices sonographic findings and comparison with C T and MR imaging
in classification of adnexal tumors with Iransvaginal color Doppler findings. J Ultrasound Med 1995:14:84:5-848.
ultrasound. J Ultrasound Obstet Gynecol 1992;2:338-344. 203. Stephenson WM. Laing FC. Sonography of ovarian fibromas.AJR
180. Brown DL. Prates MC. Laing FC et al. Ovarian masses: can be- 1985:144:1239-1240.
nign and malignant lesions be differentiated with color and pulsed 204. Alhev PA. Malone RS. Sonography of ovarian fibromas/thecoma
Doppler US? Radiology 1994:190:333-336. J Ultrasound Med 1987:6:431-436.
181. Stein SM, Laifer-Narin S. .lohnson MB et al. Differentiation of 205. Alliev PA. Butlers HL. Sonographic and CT appearance of
benign and malignant adnexal masses: relative value of grayscale, Krukenberg tumors. .J Clin Ultrasound 1984:12:205-210.
color Doppler. and spectral Doppler sonography. AJR 1995; 164: 206. Shimizu H. Yamasaki M, Oliama K et al. Characteristic ultra-
381-386. sonographic appearance of the Krukenberg tumor. J Clin Ultra-
182. Jain KA. Prospective evaluation of adnexal masses with endo- sound 1990:18:697-703.
vaginal gray-scale and duplex and color Doppler US: correlation Voi trng
with pathologic findings. Radiology 1994:191:63-67. 207. Timor-Tritsch 1L. Rottem S. Transvaginal ultrasonographic study
183. Levine D. Feldstein VA, Babcook CJ et al. Sonography of of the fallopian tube. Obstet Gynecol 1987:70:424-428.
ovarian masses: poor sensitivity of resistive index for identifying 208. Patten RM. Vincent LM, Wolner-Uanssen P et al. Pelvic inflam-
malignant lesions. AJR 1994;162:1355-1359. matory disease: endovaginal sonography with laparoscopic
184. Bromley B. Goodman II, Benacerraf BR. Comparison between correlation. J Ultrasound Med 1990:9:681-689.
sonographic morphology and Doppler waveform for the diagnosis 209. Tessler FN. Perrella RR, FIcischer AC et al. Endovaginal sono-
of ovarian malignancy. Obstet Gynecol 1994:83:434-437. grapllic diagnosis of dilated fallopian tubes. AJR 1989:153:523-
185. Salem S, While LM, Lai .J Doppler sonography of adnexal 525.
masses: the predictive value of the pulsatilily index in benign and 210. Bulas Dl, Ahlstroin PA, Sivit C.T et al. Pelvic inflammatory
malignant disease. AJR 1994:163:1147-1150. disease in the adolescent: comparison of transabdominal and
186. Carter .1, Saltxman A. Hartenbach E et al. Flow characteristics in transvaginal sonographic evaluation. Radiolog)' 1992:183:435-439.
benign and malignant gynecologic tumors using transvaginal color 211. vanSonnenberg E. D'Agostino I1B. Casola G et al. US-guided
flow Doppler. Obstet Gynecol. 1994;83:125-130. transvaginal drainage of pelvic abscesses and fluid collections.
187. Buy JN, Ghossain MA. Hngol D et al. Characterization of adnexal Radiology-1991:181:53-56
masses: combination of color Doppler and conventional sono- 212. Feld R. Eschelman DJ, Sagerman JE et al. Treatment of pelvic
graphy compared with spectral Doppler analysis alone and abscesses and other fluid collections: efficacy of transvaginal
conventional sonography alone. AJR 1996:166:385-393. sonographically guided aspiration and drainage. AJR 1994:163:
188. Fleishcr AC. Rodgers WH, Kepple DM et al. Color Doppler sono- 1141-1145.
graphy of ovarian masses: a multiparameter analysis. J Ultrasound 213. Slierer DM. Liherto 1., Abrainowicz .IS et al. Endovaginal sono-
Med 1993:12:41-48. graphic features associated with isolaled torsion of the fallopian
189. Fleischer AC, Cullinan JA, Kepple DM et al. Conventional and tube. J Ultrasound Med 1991:10:107-109.
color Doppler transvaginal sonography of pelvic masses: a com- 214. Russin LD. Hvdrosalpinx and tubal torsion: a late complication of
parison of relative histologic specificities. J Ultrasound Med 1993: tubal ligation. Radiology 1986:159:115-116.
12:705-712. 215. Subramanyam BR, Raghavendra BN. Wlialen CA et al.Ultrasonic
190. Laing FC. US analysis of adnexal masses: The art of making the features of fallopian tube carcinoma. J Ulltrasound Med 1984:3:
correct diagnosis. Radiology- 1994;191:21-22. 391-393.
191. Williams AG. Mettler FA, Wicks JD. Cystic and solid ovarian 216. Ajjunakorn S, Bhamarapravati V. Transvaginal ullrasound and the
neoplasms. Semin Ultrasound 1983:4:166-183. diagnosis of fallopian tube carcinoma. J Clin Ultrasound 1991; 19:
192. Wagner B.I. Buck JL. Seidman JD et al. Ovarian epithelial neo- 116-119
plasms: radiologic-pathologic correlation. Radiograplucs 1994:14:
1351-1374. Cac u vung chau khong thuoc phu khoa
193. Athev PA. Siegel MF. Sonographic features of Brenner tumor of 217. Wicks .11), Silver TM, Bree RL. Gray scale fealures of hema-
the ovary. J Ultrasound Med 1987:6:367-372. tomas: an ultrasonic spectrum. AJR 1978:131:977-980.
194. Brammer HM 111, Buck JL. Hayes WS et al. Malignant germ 218. Kurtz AB. Rubin CS, Kramer FL et al. Ultrasound evaluation of
the posterior pelvic compartment. Radiology 1979:132: 677-682. 224. Crani TH. Schoettle RW. Buschbaum MS. Postpartum ovarian
219. Salein S, O'Malley BP, Hiltz CW. Ultrasonographic appearance vein thrombosis: diagnosis by clot protrusion into the inferior vena
of gastrointestinal masses. J Can Assoc Radiol 1980:31:163-167. cava at sonography. AJR 1993:160:551-552.
Benh ly vung chau hau san 225. Baran CW. Uriscli KM. Duplex Doppler evaluation of puerperal
220. Lee CY, Madrazo B, Drukker BH. Ultrasonic evaluation of the ovarian vein thrombosis. AJR 1987:149:321-322.
postparrum uterus in the management of postpartum bleeding. 226. Baker ME, Kav 11. Mahonv BS et al. Sonography of the low
Obstet Gynecol 1981:58:227-232. transverse incision, cesarean section: a prospective study. J Ultra-
221. Hertzberg BS., Bowie JD. Ultrasound of the post partum uterus: sound Med 1988:7:389-393.
prediction of retained placental tissue. J Ultrasound Med 1991.- 227. Baker ME, Bowie JD. Killam AP. Sonography of post-cesarean-
10:451-456. section bladder-flap hematoma. AJR 1985:144:757-759.
222. Wilson PC, Lerner RM. Diagnosis of ovarian vein thrombophle- 228. Wiener MD, Bowie JD. Baker ME et al. Sonography of subfascial
bitis by ultrasonography. J Ulrasonnd Med 1983:2:187-190. hematoma after cesarean delivery. /\JR 1987:148:907-910.
223. Savader S.I , Otero RR. Savader BE. Puerperal ovarian vein 229. Al-Naib S. Sonographic appearance of postpartum retropubic
thrombosis: evaluation with CT. US. and MR imaging. Radiology hematoma. J Clin Ultrasound 1990:18:520-521.
1988:167:637-639.
P H A N IV
Sieu am Phan mem, ong mach Canh

va Mach mau ngoai bien
C H N G 2 1
Tuyen giap

Luigi Solbiati, M.D.
J. William Charboneau, M.D.
E. Meredith James, M.D., F.A.C.R.
Ian D. Hay, M.B., Ph.D., F.A.C.E., F.A.C.P., F.R.C.P.
hieu qua va tiet kiem, ieu quan trong la phai nam

D A N B A I ro kha nang cung nh han che cua ky thuat.
DUNG CU VA KY THUAT
DUNG CU VA KY THUAT
GIAI PHAU
BAT THNG BAM SINH CUA TUYEN GIAP
Hien nay, cac au do tan so cao (7,5-15,0 MHz)
BENH LY DANG NOT CUA TUYEN GIAP
ac tnh benh ly va tng quan sieu am cung cap va xuyen thau saulen ti 5 cm-va
Tang san va bu giap hnh anh rat ro net, phan giai t 0,7 en 1,0 mm.
Adenoma Khong co ky thuat hnh anh nao khac cho o phan
Carcinoma giai khong gian cao nh the. Ngi ta chuong au
Lymphoma do linear-array hn loai sector v co trng gan
Tien trien lam sang rong hn va co kha nang ket hp hnh anh thang
ng dung sieu am xam tan so cao vi Doppler mau. Tuyen giap la
Phat hien mot trong so nhng c quan giau mau nuoi nhat c
Phan biet the. V the, khao sat Doppler mang lai nhieu thong
Hng dan sinh thiet tin hu ch giup chan oan mot so benh tuyen giap.
Not phat hien tnh c Thong thng, benh nhan nam nga, nga co.
Kch thc Co the lot mot mieng em di hai vai benh nhan
Hnh thai sieu am giup co nga de dang hn, ac biet nhng ngi
BENH LY LAN TOA CUA TUYEN GIAP lun, map. Phai khao sat tuyen giap theo cac mat
cat ngang lan doc. Hnh anh cc di cua tuyen
hien ro hn neu bao benh nhan nuot, khi o tuyen
Nh tuyen giap nam v tr nong, ngi ta co giap di chuyen len. Phai khao sat toan bo tuyen,
the khao sat no bang sieu am thang xam, hien th ke ca eo. Cung phai kham doc hai ben me ngoai
tc th, phan giai cao va bang Doppler mau vi ket co bao gom vung mach canh e tm chuoi hach
qua thu c ve giai phau bnh thng va tnh canh ph ai, hach vung goc ham me tren va
trang benh ly ro rang mot cach ang ke. V the, ky hach ho tren on me di.
thuat nay a gi vai tro ngay cang quan trong Ngoai nhng hnh anh ghi lai thong thng
trong chan oan cac benh tuyen giap. Tuy nhien, trong khi khao sat sieu am, mot so bac s con ve lai
sieu am ch la mot trong nhieu phng phap chan s o ghi nhan v tr nhng bat thng (Hnh 21-1).
oan hien hanh oi vi tuyen giap. e s dung Ban o co giup bac s lam sang va benh nhan
704 SIEU AM PHAN MEM, ONG MACH CANH VA MACH MAU NGOAI BIEN
nam c tng quan gia giai phau va benh ly ro ng knh trc sau trung bnh la 13 en 18 mm.
rang hn. o day trung bnh cua eo la 4 en 6 mm.3
Sieu am la phng phap chnh xac giup tnh ra
GIAI PHAU the tch tuyen giap. Trong khoang mot phan ba
cac trng hp, the tch o c bang sieu am
Tuyen giap nam phan trc di cua co (khoang khac vi the tch c lng khi kham lam sang.4
di mong) trong mot khoang c gii han bi c, o the tch tuyen giap can thiet trong viec anh
kh quan, thc quan, ong mach canh va tnh mach gia bu giap e quyet nh kha nang phau thuat,
canh (Hnh 21-2). Tuyen giap gom hai thuy nam cho phep tnh toan lieu I131 can thiet e ieu tr
doc hai ben kh quan va noi lien nhau qua ng nhiem oc giap va anh gia ap ng vi ieu tr c
gia nh eo giap, mot cau truc mong ap sat thanh che.5 The tch tuyen giap c tnh bang cac thong
trc kh quan ngang ni noi phan ba gia va phan so tuyen tnh hoac chnh xac hn bang cac cong
ba di be cao tuyen. 10% en 40% ngi bnh thc toan hoc. Trong so cac thong so tuyen tnh,
thng co mot thuy giap nho (hnh thap) moc pha ng knh trc sau la chnh xac nhat v no tng
tren eo va nam oi dien sun giap.1 Thng gap oi khong le thuoc vao s bat xng ve kch thc
thuy nay ngi tre nhng no se teo dan khi cua hai thuy. Khi ng knh AP vt qua 2 cm,
trng thanh roi bien mat. Kch thc va hnh the tuyen giap c xem nh ph ai. Phng phap o
cac thuy giap thay oi nhieu ngi bnh thng. the tch tuyen giap chnh xac nhat la cong thc ket
ngi cao, cac thuy ngoai co dang thon dai khi hp t nhieu ng cat sat nhau thanh chuoi.6
cat doc trong khi ngi thap chung co dang bau tre s sinh, the tch tuyen giap thay oi t 0,40 en
duc hn. Nhn chung, kch thc bnh thng bien 1,40 ml, tang khoang 1,0 en 1,3 ml cho moi 10 kg
thien rat nhieu. tre s sinh, tuyen dai 18 en 20 tang trong cho ti the tch bnh thng ngi ln
mm con ng knh trc sau (AP) khoang 8 en 9 la 11 3 ml.6 Tuyen giap co the tch tang nhng
mm. en 1 tuoi, chieu dai trung bnh la 25 mm va ngi song trong vung thieu iot va benh nhan b
ng knh trc sau la 12 en 15 mm.2 ngi viem gan man hoac ang c ieu tr vi thyroxin
ln, chieu dai trung bnh khoang 40 en 60 mm va hoac iot phong xa.5,6
Hnh 21-1. Ban o co giup cho bac s lam sang nam c tng quan gia giai phau
va benh ly va c dung e tham khao cho cac khao sat theo doi. SMG, tuyen di ham
Tuyen Giap 705
Chu mo tuyen giap bnh thng la mot moi trong cac mach mau nuoi cac bo phan nong.
trng ong nhat co phan am mc trung bnh en Cac c c mong va vai mong hien len nh
cao nen de phat hien cac ton thng khu tru dang nhng dai mong, giam phan am nam trc tuyen
nang hoac co phan am giam trong phan ln cac giap (Hnh 21-2). C c on chum hien len nh
trng hp (Hnh 21-2). ng mong tang phan am mot dai ln hn, hnh bau duc nam pha ngoai
bao quanh cac thuy la vo bao, thng nhan dien tuyen giap. Mot moc giai phau quan trong la c
c tren sieu am. nhng benh nhan tang ure dai co nam pha sau moi thuy giap, rat sat vi
mau hoac b roi loan bien dng calcium, vo bao khoang trc cot song.
ong voi. Nh nhng dung cu Doppler o nhay cao Than kinh thanh quan quat ngc va ong
hien co, ngi ta co the thay o ti mau doi dao mach giap di chay trong goc tao bi kh quan,
cua tuyen, ro nhat cac cc tren va di (Hnh 21- thc quan va thuy giap. Khao sat ky lng bang
3). ong mach va tnh mach giap tren thay cc sieu am thang xam va Doppler mau, co the nh v
tren cua thuy. Tnh mach giap di thay cc c cac cau truc nay. Tren mat cat doc, than kinh
di va ong mach giap di nam pha sau mot quat ngc va ong mach giap di hien len nh
phan ba di moi thuy (Hnh 21-4). Khau knh mot dai mong, giam phan am, nam gia thuy giap
trung bnh cua ong mach la 1 en 2 mm, trong khi va thc quan me trai va thuy giap va c co dai
tnh mach len ti 8 mm khau knh. Bnh thng, me phai. Thc quan thng nam chech ve me trai.
van toc nh tam thu len den 20 en 40 cm/giay Tren mat cat ngang, no hien len ro rang nh cac
trong cac ong mach giap chnh va 15 en 30 cau truc dang bia cua ong tieu hoa va khi benh
cm/giay trong cac ong mach trong nhu mo. Cung nhan nuot, nhan ra c nhu ong.
can lu y rang ay la nhng van toc cao nhat gap
Hnh 21-2. Tuyen giap bnh thng. A, Sieu am cat ngang vi au do linear array 7,5 MHz. . B, Hnh ve
tng ng giai phau. Tr, bong kh trong kh quan C, ong mach canh chung. J, tnh mach canh. (Trch t James
EM, Charboneau JW. Sieu am tuyen giap vi tan so cao (10 MHz). Semin Ultrasound, CT, MR 1985;6:294-309.)
Hnh 21-3. Ti mau bnh thng cua tuyen giap. A va B, cac dung cu mi ve
Doppler mau va nang lng rat nhay cam cho thay mang li mach mau doi dao cua tuyen
bnh thng tren cac hnh cat doc.
Hnh 21-4. Cac mach mau chnh cua tuyen giap tren lat cat doc. A, ong mach
giap di (mui ten) chay doc mat sau. B, Cac nhanh cua tnh mach giap di (mui ten) cc
di cua tuyen giap.
Tuyen Giap 707
BAT THNG BAM SINH CUA TUYEN 1,5 cm) nhng lai de dang phat hien c bang
GIAP sieu am phan giai cao. Cau hoi lai at ra la x tr
ra sao vi cac nhan nho phat hien tnh c bang sieu
Cac tnh trang bam sinh cua tuyen giap bao gom am va chung ta se e cap tr lai phan sau cua
vo sinh mot thuy hay toan the, cac mc o thay chng nay.
oi ve giam san va lac cho. Sieu am c s dung
e chan oan giam san bang cach cho thay kch Cac ac tnh benh hoc va tng quan vi
thc tuyen giam. Sieu am phan giai cao cung sieu am
c s dung e khao sat giam nang giap bam Tang san va phnh giap. Khoang 80% benh
sinh.7 o cac thuy giap dung e phan biet vo sinh giap nhan la do tang san cua tuyen va no xay ra
(khong co tuyen) vi giam nang giap do u (tuyen trong khoang 5% quan the.13 Can nguyen bao gom
ph ai). Khao sat hat nhan cung thng c s thieu iot (dch te), roi loan tao sinh hormone (the
dung hn trong viec phat hien mo giap lac cho, nh di truyen gia nh) va thieu iot do dung thuoc. Khi
cac v tr li hoac di mong. tang san dan ti tnh trang tang toan dien kch
thc hoac the tch tuyen, ngi ta goi la phnh
BENH TUYEN GIAP DANG NOT giap. Tuoi gap nhieu nhat la trong khoang 35 en
50 tuoi, phu n mac cao gap ba lan nam gii.
Nhieu benh cua tuyen giap co bieu hien lam sang Ve mat mo hoc, giai oan khi phat la tang
la mot hoac nhieu not. Nhng nhan ay the hien san te bao cua cac tieu thuy tuyen, ke o la s
nhng van e lam sang thong thng hoac con hnh thanh cac nhan nho va nhan ln. Cac nhan
nhieu ban cai. Cac nghien cu dch te c lng tang san thng trai qua thoai hoa hoa long kem
khoang 4% en 7% dan so Hoa Ky co nhng nhan tch tu mau, dch thanh t va chat keo. Ve benh
giap s thay c va phu n mac nhieu hn nam hoc, chung c xem la nhan keo, tang san hoac
gii.8,9 Chu anh hng di nguon phong xa ion tuyen. Nhieu ton thng dang nang cua tuyen giap
hoa se lam tang xuat o cac nhan lanh tnh va ac la nhan tang san a trai qua thoai hoa hoa long lan
tnh, 20% en 30% nhng ngi chu anh hng rong. Ve mat benh hoc, hiem thay cac nang thc
cua phong xa co mang benh giap nhan s thay.10,11 s cua tuyen giap tc co lp bieu mo phu. Trong
Mac du benh giap dang not tng oi thng qua trnh thoai hoa tao nang nay, co the dien ra voi
gap, ung th tuyen giap lai hiem va ch chiem 1% hoa lam cau truc quanh nhan tr nen tho. 5,14 Chc
tat ca cac u tan sinh ac tnh.12 Thc vay, nhn nang nhan tang san co the giam, co the van bnh
chung, a so cac nhan giap eu lanh tnh. ieu th thng hoac co the tang (nhan nhiem oc).
thach oi vi lam sang la lam sao phan biet c Ve mat sieu am, phan ln cac nhan tang san
so t nhan ac tnh vi cac nhan lanh chiem a so va hay tuyen co ong phan am vi mo giap bnh
ngha la nhan nh c benh nhan nao co ch nh thng (Hnh 21-5). Khi kch thc khoi u tang, no
phau thuat. Viec nay kha phc tap v nhieu nhan tr nen tang phan am do hien dien nhieu giao dien
giap khong co bieu hien tren lam sang (nho hn gia cac te bao va chat keo.5,15 oi khi co hnh thai
Hnh 21-5. Cac nhan tang san (dang tuyen). A, Nhan bau duc, ong nhat, phan am ong
(dau thap) vi halo mong, eu, phan am giam. B, Nhieu not tang phan am (dau thap).
phan am giam nh dang xop tuy t gap hn. Khi Adenoma. Adenoma ch chiem 5% en 10%
nhan co phan am ong hoac tang, thng co the toan bo benh giap nhan va phu n thng gap
gap mot vanh (halo) mong ngoai bien phan am gap bay lan so vi nam gii.5 Phan ln khong anh
giam (Hnh 21-5); thng la do cac mach mau hng chc nang tuyen giap, mot so nho (co the
quanh nhan va phu ne nhe do nhu mo tuyen lan di 10%) tang chc nang, phat trien t ong va co
can b chen ep. Khi s dung Doppler mau. Co the the gay nhiem oc giap. Phan ln cac adenoma
de dang phat hien cac mach mau quanh nhan.5,16,17 eu n oc nhng cung co the phat trien nh mot
Cac nhan tang chc nang (t quan) thng the hien phan cua dien tien a nhan.
nhieu mach mau quanh nhan va trong nhan.16,17 Adenoma dang nang lanh tnh la mot tan sinh
Nhng bien oi thoai hoa nhan phnh giap giap thc s vi hnh anh ac trng la chen ep mo
tng ng vi nhieu hnh thai tren sieu am: nhng lan can va co vo bao x. Nhieu phan loai nho c
vung trong phan am hoan toan do thanh dch hoac ke ti nh adenoma thai, adenoma te bao Hurthle
dch keo (Hnh 21-6, A, B); dch co phan am hoac va adenoma phoi, moi loai khac nhau tnh chat
mc dch-dch co chuyen ong tng ng vi xuat va hnh thai tang sinh te bao. Cac tnh chat te bao
huyet (Hnh 21-6, C, D);18 nhng o tang phan am cua adenoma dang nang thng khong phan biet
kem anh gia uoi sao choi do hien dien chat the c vi cac carcinoma dang nang. Xam lan bao
keo ac (Hinh2 1-6, E, F);19 cac vach ngan mong va xam lan mach mau la nhng net ac trng cua
ben trong nang co the tng ng vi nhng dai mo carcinoma dang nang va ch nhan dien c nhng
tuyen giam thau (Hnh 21-6, G, H). Tren Doppler tnh chat nay qua phan tch mo hoc hn la te bao
mau, nhng vach ngan nay khong co mach mau. hoc. V the, sinh thiet kim khong phai la phng
Nhng choi nhu trong nang cung thng gap, co phap tin cay e phan biet gia carcinoma dang
tn hieu Doppler hoac khong va hnh anh giong vi nang va adenoma te bao. Do o, can phau thuat
carcinoma nhu dang nang cua tuyen giap.16,17 lay bo cac u nay.
Hnh 21-6. Bien oi thoai hoa dang nang cua cac nhan tuyen (keo). A, Ton thng nang thuan tuy,
nho. B, Nhan ac giam phan am, thoai hoa nang. C va D, Xuat huyet trong nhan dang nang; lp can lang vi
mc ngang tren t the nam nga (C) va thang ng khi benh nhan ng (D).
Tuyen Giap 709
Ve mat sieu am, adenoma thng la nhng u nh ang c chan oan Bac My.
ac, co the co phan am tang, ong hoac giam. Mac du co the xay ra bat c tuoi nao, ung
Chung thng co mot vanh ngoai vi giam phan am, th dang nhu anh hng ac biet ti benh nhan
thng day va trn eu (Hnh 21-7, A). Vanh nay tre tuoi.12 N gii b nhieu hn nam gii. Tren
do bao si va cac mach mau, thay de dang tren khao sat vi the, khoang 20% cac trng hp, u co
Doppler mau. Thong thng, cac mach mau i t nhieu o ben trong tuyen giap. 22 Trong khoang 25%
ngoai bien vao vung trung tam cua nhan, tao nen cac trng hp co the gap voi hoa tron hoac det
hnh anh nan hoa banh xe (Hnh 21-7, B). Cac u (the psammoma). ng lan truyen chnh cua
tuyen tang sinh (t quan) oi khi the hien dong carcinoma dang nhu la ng bach huyet en cac
mau doi dao ngoai bien hoac ben trong (Hnh 21- hach lan can vung co. Thc vay, khong the thng
8).20 gap trng hp benh nhan co nhieu hach ph ai
Carcinoma. oi vi a so benh nhan b ung vung co ma tuyen giap s kham bnh thng.23 Mot
th tuyen giap nguyen phat, u thng co nguon goc ieu ly thu la thong thng, s hien dien cua cac
bieu mo va phat sinh t te bao nang hoac can hach vung co khong anh hng en tien lng cua
nang.12 Cac u giap ac tnh co nguon goc trung mo benh. Di can xa rat hiem (2% en 3% cac trng
rat hiem nh di can vao tuyen giap. a so ung th hp) va phan ln xay ra trung that va phoi. Sau
tuyen giap biet hoa tot va carcinoma nhu (gom ca 20 nam, t vong do ung th dang nhu cua tuyen
carcinoma hon hp dang nang va nhu) hien chiem giap ch khoang 4% en 8%.23
khoang 75% en 90% cac trng hp.12,21 Ngc Carcinoma dang nhu co tnh chat mo hoc ac
lai, carcinoma giam biet hoa, dang nang, tuy, ket biet (vo bao si, ong voi nho) va tnh chat te bao
hp, ch chiem 10% en 25% cac carcinoma giap ac biet (nhan knh uc, cac the vui te bao chat
Hnh 21-6, tiep theo. Bien oi thoai hoa dang nang cua cac nhan tuyen (keo). E va F, Nhng o
sang, tang phan am (mot so kem anh gia uoi sao choi) trong dch keo va vach. G va H, nhieu vach ngan trong
nang co be day thay oi lam ton thng co nhieu thuy. Lu y khong co dong mau trong cac vach day nay.
Hnh 21-7. Adenoma dang nang. A, cat doc cho thay mot khoi ln, ac, ong phan am va vanh hao day ngai
vi khong lien tuc (mui ten). B, Hnh anh Doppler nang lng cho thay nguon cung cap mau trong nhan tao hnh anh
nan hoa banh xe. ien hnh cua u tan sinh dang nang.
ben trong nhan va cac dau nhan tren mang nhan)

thng giup cho chan oan benh hoc tng oi de
dang.24 ac biet, rat thng gap cac ong voi nho
do tch tu cua muoi calcium trong cac the
psammoma trong ca u nguyen phat lan di can
hach co.25 Carcinoma nho dang nhu la mot u x
cng khong co vo bao co kch thc bang hoac nho
hn 1 cm. Trong 80% cac trng hp, benh nhan
bieu hien hach co ph ai va tuyen giap s kham
bnh thng.23,24
Giong nh cac tnh chat benh hoc, cac tnh
chat sieu am cua carcinoma dang nhu cung
tng oi khac biet trong a so cac trng hp:
giam phan am (trong 90% cac trng hp) do
cac thanh phan te bao sat chat nhau kem t
chat keo (Hnh 21-9, A);
ong voi nho hien len di dang nhng o li ti,
dang cham, tang phan am, co hoac khong co
bong lng (Hnh 21-9, A ,B);14,26,27
Hnh 21-8. Adenoma tang chc nang. Hnh anh cat giau mach mau (trong 90% cac trng hp),
doc tren Doppler mau cho thay nguon mach mau manh mach mau mat to chc nhat la oi vi cac u co
ngoai vi va ben trong nhan (mui ten).
vo bao ro (Hnh 21-10);28
di can hach co co the mang nhng ong voi li
ti. oi khi, di can hach co dang nang , hau qua
cua tnh trang thoai hoa lan rong (Hnh 21-11,
21-12). Di can hach bach huyet dang nang vung
Tuyen Giap 711
Hnh 21-9. ong voi nho trong cac carcinoma. A, Nhan ac phan am giam cha nhieu not voi hoa
nho li ti dang cham. ay la hnh thai ien hnh cua carcinoma dang nhu. B, Nhan ac ong phan am cha
nhieu o tang phan am dang cham. ay la carcinoma dang nhu. C, Nhan ac khong ong nhat cha nhieu o
nho tang phan am. ay la carcinoma dang tuy. D, The psammoma ong voi t mau benh hoc cua carcinoma
dang nhu.
Hnh 21-10. Carcinoma dang tuy giau mau nuoi. Hnh sieu am cat doc A, Doppler mau va
B, Doppler nang lng cho thay nguon mach mau doi dao ben trong nhan (ben trong long).
HNH ANH IEN HNH CUA CARCINOMA

NHU CUA TUYEN GIAP
Khoi u ac giam phan am

Nhng o nho tang phan am do voi hoa li ti
Doppler mau cho thay giau mach nuoi
Di can hach bach huyet vung co
cung nh xam lan mo giap lan can. Ca hai bien the

cua carcinom dang nang eu co khuynh hng lan
theo dong mau hn la theo ng bach huyet va
cho di can xa en xng, phoi, nao va gan hn la di
Hnh 21-11. Hach bach huyet bnh thng vung can hach bach huyet vung co. The xam lan rong di
co. Hnh cat doc cho thay hach lanh tnh ien hnh (mui
can trong 20% en 40% cac trng hp va the xam
ten) vi hnh thai thon dai. Dai co phan am dang thang
ben trong bieu hien ron m cua hach. S, c c on chum lan t ch khoang 5% en 10% cac trng hp. T
vong do carcinoma dang nang khoang 20% en
30% vao 20 nam sau mo.12,23
co thng i kem vi carcinom giap dang nhu Khong co mot tnh chat duy nhat nao co the
nhng oi khi gap trong carcinom vom hau.29 giup phan biet carcinoma dang nang vi adenoma
Carcinoma dang nang la loai ung th giap dang nang nen cung khong co g ngac nhien khi
biet hoa tot th hai. No chiem 5% en 15% cac tnh chat te bao va mo hoc cua hai u cung giong
trng hp ung th tuyen giap, anh hng n gii nhau. Cac tnh chat gi y carcinoma dang nang bao
nhieu hn nam gii.12 Co hai bien the carcinoma gom ng b khong eu, vanh halo day, khong
dang nang va chung khac nhau nhieu ve mo hoc eu va phan bo mach mau ben trong u ngoan
cung nh dien tien lam sang.21,24 Carcinoma dang ngoeo hon on khi khao sat Doppler mau (Hnh
nang xam lan t co vo bao va ch qua phan tch mo 21-13).16,29
hoc mi biet c xam lan khu tru mach mau vo Carcinoma dang tuy ch chiem khoang 5%
bao si giup phan biet vi adenoma dang nang. tong so benh giap ac tnh. No phat sinh t te bao
Carcinoma dang nang xam lan rong khong co vo can nang tc te bao C va tiet ra hormone
bao ro va de dang thay c xam lan mach mau calcitonin, ay la mot marker hu ch trong huyet
Tuyen Giap 713
Hnh 21-13. Carcinoma dang nang ln. Hnh cat doc cho
thay mot khoi ac khong ong nhat vi dong mau ngoai bien
va ben trong u
AC TNH SIEU AM CUA CARCINOMA

DANG NHU CUA TUYEN GIAP
U co ng b khong eu
Vanh halo day, khong eu
Cac mach mau ben trong u phan bo ngoan ngoeo va
hon on
b carcinoma tuy hn carcinoma nhu (Hnh 21-14).

Nhng o tang phan am, sang, dang cham do cac o
thoai hoa tinh bot hoac voi hoa gap trong 80% en
90% carcinoma tuy.31 Co the thay nhng o nay
khong ch trong u nguyen phat ma ca trong di can
hach va ca di can gan.
Carcinoma giap giam biet hoa la benh chu
yeu ngi gia, la mot trong nhng u ac gay t
Hnh 21-12. Di can en hach co t carcinoma dang vong cao. Tuy ch chiem 5% toan bo cac ung th
nhu. A, Hai hach tron va co phan am giam. ay la hnh anh tuyen giap, tien lng lai rat xau, t vong sau 5
ien hnh cua hach di can vung co. B, cac hach bau duc nam len en 95%.32 ien hnh, la mot u ln nhanh,
khong ong nhat cha nhng ong voi li ti (mui ten). C, Hach lan ra xa tuyen va xam lan cac cau truc lan can.
dang nang (mui ten). Mot hach cha nhng not ac (au mui
Khi bieu hien thng a khong the mo c.
ten) moc t vach.
Carcinoma tren co the i kem vi carcinoma
thanh. Ung th nay mang tnh gia nh (20%) va la nhu hoac nang, lam u tan sinh kem biet hoa.
mot thanh phan thiet yeu trong hoi chng a u tan Chung thng khong lan theo ng bach huyet
sinh noi tiet (MEN: multiple endocrine neoplasia) ma xam lan tai cho vao cac c va mach mau lan
typ II.30 Benh xay ra nhieu ni, hai ben trong can.24 Ve mat sieu am, nhng carcinoma nay co
khoang 90% cac trng hp gia nh.12 Xuat o di phan am giam va thng bao quanh hoac xam lan
can hach cao va tien lng c xem nh phan nao mach mau va xam lan c co (Hnh 21-15). Thong
xau hn ung th dang nang. thng, sieu am khong khao sat ay u loai u nay
Hnh anh sieu am cua carcinoma dang tuy do kch thc qua ln. Thay vao o, CT hoac MRI
giong nh carcinoma dang nhu. Xam lan tai cho va vung co thng cho thay o lan rong cua benh mot
di can hach co thng xay ra nhng benh nhan cach chnh xac hn.
Hnh 21-14. Huyet khoi trong tnh mach canh trong

va hach ph ai. Hnh cat doc cho thay hach ph ai (mui
ten) va khuyet khoi u ben trong tnh mach canh (V) phat sinh
t carcinoma o cao.
AC TNH SIEU AM CUA CARCINOMA GIAM

BIET HOA CUA TUYEN GIAP
Khoi giam phan am

Bao quanh hoac xam lan mach mau
Xam lan cac c vung co
Lymphoma. Lymphoma chiem khoang 4%

tong so u ac tnh tuyen giap. Phan ln thuoc loai
khong Hodgkin va thng xay ra phu n ln tuoi.
Dau hieu lam sang ien hnh la u tang trng
nhanh gay ra nhng trieu chng tac nghen nh kho
Hnh 21-15. Carcinom giam biet hoa. Hnh cat doc cho
th va nuot kho.33 Trong 70% en 80% cac trng thay mot khoi ac, phan am giam (mui ten) phat sinh t phan
hp, lymphoma phat sinh t benh ly viem giap sau di cua tuyen giap va lan rong vao trong trung that tren.
man tnh dang lympho a co san (benh Hashimoto)
vi dau hieu suy giap. Tien lng bien thien ang
ke tuy theo giai oan cua benh. Ty le song 5 nam Moi mot ky thuat co nhng li iem va gii han va
t gan 90% trong giai oan sm en di 5% khi viec la chon mot hoac nhieu ky thuat tuy theo
a tien trien, lay lan. tng tnh huong lam sang ac biet cung nh tnh
Ve mat sieu am, lymphoma giap hien len nh hnh may moc va kinh nghiem cua chuyen gia.
mot u a thuy, phan am giam, gan nh khong co Nhn chung, hien nay, sinh thiet kim nho
mach mau. Nhng vung hoai t nang lan rong cung (FNA) la phng phap hieu qua nhat trong chan
nh boc quanh cac mach mau co lan can.34 Nhu mo oan tnh ac cua mot nhan giap.36-38 Trong thc te
giap xung quanh tr nen khong ong nhat do ket lam sang, thc hien FNA ngay di s kham trc
hp viem giap man tnh.35 tiep khi phat hien nhan giap. Khong dung ong v
phong xa hoac sieu am mot cach thng quy. Thay
Khao sat lam sang vao o, chung c danh cho nhng tnh huong ac
Mot khi phat hien mot nhan giap, van e can ban biet hoac nhng trng hp kho. FNA co u iem
la xac nh no lanh tnh hoac ac tnh. Ngoai viec trong x tr nhan giap v no mang lai thong tin trc
phau thuat lay bo, nhieu phng phap nh tnh tiep hn bat c ky thuat chan oan nao khac. No
nhan ang c s dung rong rai bao gom hnh anh an toan, khong at tien va giup chon loc benh nhan
hoc hat nhan, sieu am va sinh thiet kim nho (FNA). c phau thuat tot hn. Tuy nhien, viec s dung
Tuyen Giap 715
BANG 21-1
KET QUA CHAN OAN CUA CHOC HUT TUYEN GIAP BANG KIM NHO (FNA)
So Ty le am gia Ty le dng gia o nhay cam o chuyen biet
Nghien cu Trng hp % % % %
Hawkins va cs.41 1399 2,4 4,6 86 95

Khafagi va cs.42 618 4,1 7,7 87 72
Hall va cs.43 795 1,3 3,0 84 90
Altavilla va cs.44 2433 6,0 0,0 71 100
Gharib va cs.40 10971 2,0 0,7 98 99
Ravetto va cs.45 2014 11,2 0,7 89 99
Chnh sa t Gharib H., Goellner JR.,Sinh thiet choc hut bang kim nho tuyen giap: anh gia. Ann Intern Med 1993;118:282-289
thanh cong FNA tren lam sang rat le thuoc vao

kinh nghiem cua ngi choc hut cung nh trnh o NG DUNG CAN BAN CUA SIEU AM
cua chuyen gia giai phau benh. TRONG VIEC ANH GIA BENH GIAP NHAN
Choc hut tuyen giap bang kim nho a c cac
Xac nh v tr cua mot khoi s c vung co
nha giai phau benh chia thanh bon loai:
(tc trong hay ngoai tuyen giap)
am tnh (khong co te bao ac tnh); nh tnh nhan: lanh hoac ac
dng tnh ac tnh; Phat hien cac nhan an benh nhan co benh s tia xa
nghi ng ac tnh; hoac vung au co tc hoi chng MEN-II
khong chan oan c. Xac nh o lan rong cua ton thng giap ac tnh
Neu nhan c xep vao mot trong hai loai ben Phat hien carcinoma con sot, tai phat hoac di can
tren, ket qua mang tnh chuyen biet va nhay cam Hng dan choc hut bang kim nho cac nhan giap
cao.39 Han che chnh cua ky thuat nay la thieu tnh hoac hach co
chuyen biet trong nhom ma ket qua nghi ng ac
tnh, trc tien v khong co kha nang phan biet u
tuyen dang nang tc te bao Hurthle vi phan ac ng dung sieu am
tnh. Trong nhng trng hp nay, phai phau thuat Mac du FNA a tr thanh phng phap chan
lay bo e chan oan. Hn na, ti 20% cac trng oan au tien trong viec anh gia lam sang cac
hp choc hut khong cho chan oan, khoang phan nhan giap s c, sieu am phan giai cao co ba
na la do ton thng dang nang nen khong lay u ng dung lam sang ban au gom:46-48
mau te bao. Trong nhng trng hp nay, thc phat hien cac u tuyen giap va u khac vung co
hien lai FNA di hng dan cua sieu am giup trc va sau khi cat tuyen giap;
chon loc phan ac cua khoi u. FNA nhan giap co phan biet u lanh va ac da tren hnh anh sieu
o nhay khoang 65% en 98% va o ac hieu t am; va
72% en 100% vi ty le am gia t 1% en 11% va hng dan FNA
dng gia 1% en 8% (Bang 21-1).40 Theo kinh Phat hien. Viec s dung can ban va thong
nghiem cua chung toi, o chnh xac tong the cua dung cua sieu am la xac nh v tr giai phau chnh
FNA vt qua 95% va nh vay hien la phng xac cua khoi u s c vung co. Thong thng,
phap chnh xac nhat, hieu qua/gia ca thiet thc ch tham kham s nan lam sang khong phai luon
trong viec anh gia s khi benh ly nhan giap. Ke luon xac nh c u s thay nam ben trong hay ke
t khi FNA c a vao s dung thng quy tren can tuyen giap. Sieu am de dang phan biet u trong
lam sang, ty le phan tram so benh nhan phai cat tuyen giap vi u khac vung co nh nang thanh dch,
tuyen giap a giam ang ke (khoang 25%) va chi nang giap li hoac hach co ph ai. Ngoai ra, sieu
ph cham soc nhan giap cung giam khoang 25%.40 am con giup khang nh s hien cua nhan giap khi
Bac My va Bac Au, rat thng anh gia ban cac dau hieu kham lam sang con m ho.
au nhan giap bang FNA. mot so nc Chau Au Sieu am giup phat hien cac nhan giap tiem an
khac va Nhat ban, viec anh gia thng da tren benh nhan co benh s tia xa vung au co khi
hnh anh hoc hat nhan va sieu am. con nho cung nh nhng ai co benh s gia nh ve
Hnh 21-16. Phnh giap a hat. A, Hnh cat doc cho thay nhieu nhan (N) ong phan am
va tang phan am va tren Doppler mau (B) bieu hien ti mau ngoai bien.
hoi chng MEN-II v ca hai nhom nay mang nguy viec sieu am phat hien them vai nhan khac khong
c cao phat trien benh ly ac tnh tuyen giap. Neu phai la dau hieu tin cay e loai tr tnh ac.
tm thay nhan giap, co the thc hien sinh thiet di nhng benh nhan a biet ung th tuyen giap,
hng dan cua sieu am. Tuy nhien, ngi ta cung sieu am cung ch li e xac nh mc lan rong
khong biet rang viec phat hien ung th sm trc cua benh, ca tien phau va hau phau. Trong a so
khi s c u tren lam sang co thay oi c tien cac trng hp, thc hien sieu am thng quy trc
lng cho benh nhan hay khong. khi cat tuyen giap va ac biet hu ch oi vi
Trc ay, khi anh gia nhan giap bang ong nhng u ln vung co nham anh gia cac cau truc
v phong xa, ngi ta thng chap nhan rang mot lan can nh ong mach canh va tnh mach canh
nhan lanh n oc mang tnh ac khoang 15% en trong, tm bang chng xam lan hoac bao quanh
25%, trong khi mot nhan lanh trong mot tuyen a mach mau. Ngoai ra, oi vi benh nhan co hach co
nhan ch co 1% ac tnh.49 Tuy nhien, phnh giap ph ai do ung th giap dang nhu nhng tuyen giap
lanh tnh mang a nhan trong 70% en 80% cac co the bnh thng, dung sieu am tien phau e
trng hp, va gan ay, ngi ta thay rang 70% phat hien nhng nhan nguyen phat tiem an, khong
cac nhan c coi la n oc tren xa hnh hoac s thay nam ben trong tuyen.
kham lam sang thc ra la a nhan khi c kham Sau khi cat tuyen giap ban phan hoac gan tron
lai bang sieu am tan so cao (Hnh 21-16).18,50 v ung th, sieu am la phng phap c a chuong
V the, ngi ta e ngh s dung sieu am e e phat hien benh ly con sot, tai phat hoac di
phat hien them nhng nhan tiem an khac nhng can vung co.53 benh nhan a c cat ban
benh nhan a phat hien c nhan n oc tren phan tuyen giap, hnh anh sieu am cua mo giap
lam sang. Ve phng dien benh hoc, nhan lanh con lai la yeu to quan trong e quyet nh xem co
cung thng ket hp vi nhan ac. Trong chuoi nen cat toan phan tuyen giap hay khong. Neu nhan
nghien cu mi ay tren 1500 benh nhan a c dien mot khoi u, phai dung FNA di hng dan
mo v carcinoma nhu, 33% ket hp nhan lanh tnh cua sieu am e xac nh ban chat cua u (Hnh 21-
hien hu vao thi iem phau thuat.51 Ngoai ra, ung 17). Neu khong tm thay u, bac s lam sang co the
th giap dang nhu hien dien a o trong t nhat 20% cho theo doi vi cac sieu am nh ky. oi vi benh
cac trng hp va tiem an (tc co ng knh di nhan a c cat tron hoac gan tron tuyen giap,
1,5 cm) ti 48% cac trng hp.22,51 Trong cac sieu am cang nhay hn kham lam sang trong viec
nghien cu gan ay, gan nh hai phan ba (64%) so phat hien benh tai phat ben trong ho giap hoac di
benh nhan co ung th tuyen giap co t nhat mot can hach co.54 Benh nhan co benh s ung th giap
nhan i kem vi nhan chnh kham thay tren sieu phai trai qua sieu am nh ky vung co e phat hien
am.52 Tren phng dien benh hoc, nhng nhan kem benh ly ac tnh khong s thay hoac di can. Khi
them nay co the lanh hoac ac. Do o, nhng nhan dien u, FNA di hng dan cua sieu am
benh nhan phat hien nhan n oc tren lam sang, giup xac nh chan oan ac tnh va giup len
Tuyen Giap 717
Hnh 21-17. Carcinoma nhu tai phat trong ho giap sau khi a cat tuyen giap. A, Hnh
cat ngang vung co ben phai cho thay mot khoi ac 1 cm (mui ten) nam me trong ong mach canh (C)
va tnh mach canh (J). B, FNA di hng dan cua sieu am vi bong kim hien len ben trong khoi u
chng trnh phau thuat. lien quan ti s hien dien cua chat the keo (Hnh
Phan biet. Hien nay, khong mot tieu chuan 21-6, E). Trong mot nghien cu mi cong bo, sinh
sieu am n oc nao phan biet c nhan giap thiet FNA lanh tnh trong tat ca cac trng hp.19
lanh tnh vi nhan ac tnh mot cach thc s tin Nhng anh gia uoi sao choi nay co the sinh t
cay.29,55 Tuy nhien, mot so tnh chat sieu am c trong thanh va t cac vach ngan hoac t trong dch
mo ta thng gap mot loai mo hoc nay hoac kia, nang. Khi mot thanh phan ac hn tu trong phan
t o thiet lap c hng chan oan chung (Bang thap cua cau truc nang, a phan la do chat lang t
21-2).29 Cac tnh chat giai phau can ban cua mot xuat huyet (Hnh 21-6, C, D). Benh nhan b xuat
nhan giap tren sieu am phan giai cao bao gom: huyet thng bieu hien lam sang qua mot khoi u
cau truc ben trong (ac, nang ac hon hp, co ln nhanh va au.
thuan tuy dang nang); Carcinoma dang nhu hiem bieu hien thoai hoa
phan am so tng oi vi nhu mo tuyen giap nang va hien len dng nh khac han cac nhan
lan can lanh tnh dang nang.56 Tuy nhien, trong carcinoma
ng b nhu dang nang, phat hien c mot choi ac (1 cm
s hien dien va hnh thai voi hoa hoac ln hn vi tn hieu dong mau kem voi hoa li
vanh halo phan am giam ngoai vi; va ti hoac khong) vao trong long co the khien nghi
s hien dien va phan bo cua dong mau. ng ac tnh (Hnh 21-18). Di can hach co ung th
Cac cau truc ben trong. Theo kinh nghiem nhu dang ac hoac nang co the hien len di dang
cua chung toi, khoang 70% cac nhan giap la ac nang thuan tuy, khi xay ra nh vay tuy hiem,
trong khi 30% con lai bieu hien t nhieu bien oi dng nh la dau hieu thc s cua hach ac tnh
dang nang. Mot nhan co mot thanh phan nang quan (Hnh 21-12).
trong thng la nhan tuyen (keo) lanh tnh a trai Phan am. Ung th tuyen giap thng giam
qua thoai hoa hoac xuat huyet. Khi phat hien c phan am so vi nhu mo tuyen giap bnh thng lan
bang may cu, phan giai kem, cac ton thng nay can (Hnh 21-9). That khong may man khi nhieu
eu c xem la nang v khong nhn thay s hien nhan lanh tnh cung co phan am giam. Thc vay,
dien cua chat lang ben trong cung nh o day cua phan ln nhan giam phan am la lanh tnh v nhan
vach. Ve mat benh hoc, hiem gap mot nang giap lanh tnh xay ra nhieu hn nhan ac tnh. Mot nhan
n gian thc s co lp bieu mo che phu. Dng chu yeu tang phan am nhieu kha nang lanh tnh
nh khi khao sat bang sieu am phan giai cao, tat ca (Hnh 21-5, B).18 Nhan ong phan am (thay c
cac nang eu co vach phan nao khong eu va mot nh vien ngoai bien giam phan am ngan cach nhan
so thanh phan lang ben trong do thoai hoa nhan vi nhu mo tuyen bnh thng) mang nguy c trung
(Hnh 21-6). Anh gia uoi sao choi thng gap gian ve tnh ac (Hnh 21-5, A).
trong cac nhan giap dang nang va dng nh co Halo. Mot vanh giam phan am ngoai vi, lien
BANG 21-2
O TIN CAY CUA CAC AC TNH SIEU AM TRONG VIEC PHAN BIET CAC NHAN GIAP LANH TNH VI AC TNH *
Chan oan benh hoc
Cac ac tnh sieu am Lanh tnh Ac tnh
Cau truc ben trong
Dang nang thuan tuy ++++ +
Dang nang vi vach ngan mong ++++ +
Hon hp ac va nang +++ ++
Anh gia uoi sao choi +++ +
o phan am
Tang phan am ++++ +
ong phan am +++ ++
Giam phan am +++ +++
Vanh halo
Halo mong ++++ ++
Halo day khong lien tuc + +++
ng b
Ro net +++ ++
Khong ro ++ +++
ong voi
Dang vo trng ++++ +
Dang tho +++ +
Nho li ti ++ ++++
Doppler
Ti mau ngoai bien +++ ++
Ti mau ben trong ++ +++
+ = hiem (<1%); ++ = kha nang thap (<15%); +++ = kha nang trung gian (16% en 84%); ++++ = kha nang cao (>85%)
* da tren kinh nghiem cua cac tac gia va y van
tuc hoac khong lien tuc quanh mot nhan giap co nhan lanh nhng tiec thay ch gap trong so t cac
the gap trong 60% en 80% cac nhan lanh tnh va nhan lanh tnh (Hnh 21-20). Nhng o voi hoa tang
trong 15% cac ung th tuyen giap.18,57 Ve mat mo phan am rai rac lai thng gap, co bong lng hoac
hoc, ngi ta ngh rang o la bieu hien cua vo bao khong. Khi nhng ong voi nay ln va tho, nhan
nhan nhng nhng nhan tang phan am khong co vo cung co khuynh hng lanh tnh hn. ong voi nho
bao thng van co hnh anh sieu am nay. Gia dang cham lai hng ve nhan ac tnh. Ve mat
thuyet rang o la do s chen ep nhu mo tuyen giap benh hoc, nhng ong voi nho nay do cac the
bnh thng de chap nhan hn nhat la oi vi psammom tao nen, thng thay trong ung th dang
nhng ung th giap phat trien nhanh, mang vanh nhu (Hnh 21-9).
halo day, khong eu (Hnh 21-19), co t hoac Carcinoma giap dang tuy thng bieu hien
khong co mau ti tren Doppler mau. Hnh anh nhng o sang tang phan am ben trong u nguyen
hoc Doppler mau va Doppler nang lng cho thay phat hoac trong cac hach di can.31 Nhng o ln
halo ngoai bien, mong, tron ven gi y nhieu ti thng kem bong lng. Ve mat benh hoc, chung
nhan lanh tnh, vi phan bo mach mau ngoai bien tao nen t phan ng x hoa va ong voi quanh cac
ton thng (dang ro). cho tch tu tinh bot, ien hnh cua ung th dang tuy.
ng b. Cac nhan giap lanh tnh thng co Tuy benh canh lam sang tng thch (nh hoi
ng b ro net, trong khi cac nhan ac tnh co chng MEN-II hoac benh nhan co calcitonin huyet
ng b khong eu hoac khong ro net. Tuy nhien, thanh tang cao), viec phat hien cac o tang phan am
ng trc mot nhan nao o, khong the da tren ben trong mot nhan giap phan am giam hoac trong
hnh anh ng vien ben ngoai e d oan tnh mot hach co co the giup hng nhieu ti carcinoma
chat mo hoc v co rat nhieu ngoai le. dang tuy (Hnh 21-9, C).
ong voi. Co the phat hien ong voi trong Da tren kinh nghiem ca nhan va y van, vi
10% en 15% cac nhan giap nhng v tr va hnh ac tnh sieu am a dang, ong voi nho li ti cho
thai co kha nang giup phan biet ton thng lanh thay o chnh xac cao nhat (76%), o chuyen biet
tnh vi ac tnh.18 ong voi ngoai bien, dang vo (93%) va gia tr d oan dng cao (70%) oi vi
trng dng nh la ac tnh tin cay nhat cua mot tnh ac khi ch s dung mot dau duy nhat, tuy nhien
Tuyen Giap 719
Hnh 21-18. Khao sat Doppler cac nhan dang nang. A va B cho thay mot nhan ben trong mot
ton thng dang nang. Doppler mau cho thay khong co dong trong nhan; ay la mot nhan tuyen keo
thoai hoa. C va D cho thay mot nhan ben trong mot ton thng dang nang nhng nhan nay co dong ben
trong. Hnh thai nay gi y the nang hiem gap cua carcinoma dang nhu, sau o a c khang nh.
o nhay cam thap (36%) va khong u tin cay e

phat hien benh ly ac tnh.26,27d9
Hnh thai dong Doppler. Qua cac khao sat
mo hoc, ngi ta a biet rat ro la phan ln cac
nhan tang san la nhng ton thng t mau ti va t
mau ti hn nhu mo giap bnh thng. Ngc lai,
phan ln cac carcinoma giap biet hoa tot giau
mach nuoi, vi cac mach mau ngoan ngoeo khong
eu va nhng thong noi ong-tnh mach (Hnh 21-
10). Carcinoma giam biet hoa thng t mach
mau do hoai t lan rong kem vi s tang trng
nhanh cua u.
V phan tch nh lng van toc dong khong Hnh 21-19. Carcinoma dang nhu tiem an. Mot
chnh xac trong phan biet lanh va ac, ac tnh nhan ong phan am (dau thap) ng knh 1,3 cm vi
vanh hao day va khong eu.
Doppler duy nhat co the hu ch la s phan bo cua
cac mach mau. Vi ky thuat hien tai, khong co
Trong nhng nam gan ay, nhieu bai bao e

cap en o tin cay cua sieu am (thang xam va
Doppler mau/nang lng trong viec phan biet nhan
giap lanh tnh vi ac tnh (Bang 21-3). Mac du
khong mot ac tnh sieu am nao thc s ac hieu
cho tnh ac, ty le cao ve o nhay cam, o chuyen
biet va o chnh xac chng to sieu am co the ho
tr cho FNA.
Hng dan sinh thiet. Sinh thiet bang kim cac
khoi u vung co di hng dan cua sieu am a tr
thanh mot ky thuat quan trong trong nhieu tnh
huong lam sang. Li iem chnh cua no la mang
lai hnh anh hien th tc th va lien tuc cua bong
kim, yeu to het sc can thiet khi sinh thiet ton
thng nho. a so bac s dung kim 25G va hut vi
ong tiem. Nhng bao cao gan ay cho thay viec s
dung nhng kim cat ln, t ong cai thien nhieu
trong chan oan benh hoc.68,69 Ky thuat sinh thiet
di hng dan cua sieu am c trnh bay chi tiet
trong Chng 17.
Co the sinh thiet nhng nhan giap s thay
c ma khong can hng dan cua hnh anh hoc.
Ba tnh huong oi hoi ch nh sinh thiet co hng
dan. Th nhat, kham lam sang nghi ng nhan giap
nhng khong s c mot cach chac chan. Khi o,
sieu am giup xac nh s hien dien cua nhan va
hng dan sinh thiet chnh xac. Th hai, benh nhan
co nguy c cao ve ung th tuyen giap, kham lam
Hnh 21-20. ong voi lanh tnh. A, ong voi tho
sang bnh thng nhng sieu am phat hien nhan.
ngoai bien kem bong lng. B, ong voi ngoai bien dang vo
trng.
Kem luon trong nhom nay la benh nhan co tien s
tia xa vung au co, benh nhan co benh s gia nh
nhan giap nao hoan toan khong co mach mau tren dng tnh vi hoi chng MEN-II va nhng benh
Doppler mau hoac nang lng. Hai dang phan bo nhan a trai qua phau thuat cat bo ban phan tuyen
mach mau chnh la ti mau ngoai bien va ti giap trc o v ung th. Nhom th ba bao gom
mau ben trong long nhan (kem ngoai bien hoac nhng benh nhan a c sinh thiet qua s nan
khong).16,17,59 Ngi ta nhan thay rang 80% en trc tiep nhng khong chan oan hoac ket luan
95% cac nhan tuyen, phnh giap va tang san co c. Thong thng, khoang 20% cac mau lay t
ti mau ngoai bien (Hnh 21-16), trong khi 70% sinh thiet qua s nan khong cho ket luan c ve
en 90% benh ly ac tnh cua tuyen giap bieu hien te bao hoc, a so v ch hut phai dch trong ton
ti mau ben trong, co kem them ngoai bien thng dang nang. Co the s dung sieu am trong
hoac khong (Hnh 21-10).16,28,60,61 Dng nh chnh nhng trng hp nay e chon loc choc kim vao
cac the he may Doppler mi vi o nhay cao vi phan ac cua ton thng (Hnh 21-23).
dong mau a lam gia tang ang ke s nham lan v nhng benh nhan a c cat tuyen giap v
tm thay mach mau ben trong long oi vi nhan carcinom, FNA-sieu am tr thanh phng phap
lanh va lam giam o tin cay cua cac ac tnh quan trong trong chan oan sm benh ly tai phat
Doppler. Ngi ta cung cha biet ro viec s dung vung co. Theo kinh nghiem cua chung toi tren 54
chat tng phan trong sieu am co cai thien c o sinh thiet cac u vung co, o chnh xac len ti 94%.
chnh xac cua Doppler hay khong (Hnh 21-21, Trong so 54 u thay tren sieu am, 44 khong s thay
Hnh 21-22). khi kham lam sang.54 nhng benh nhan a c
Tuyen Giap 721
Hnh 21-21. Hnh thai lanh tnh cua dong mau ti quanh nhan trc va sau khi tiem
chat tng phan. A, Doppler nang lng cho thay dong chay chu yeu ngoai bien cua nhan tuyen
lanh tnh nay. B, sau khi tiem chat tng phan (bong kh nho li ti), Dong chay quanh nhan hien ro hn.
BANG 21-3
O CHNH XAC CUA SIEU AM TRONG VIEC PHAN BIET CAC NHAN GIAP LANH TNH VI AC TNH
Tac gia o nhay cam o chuyen biet o chnh xac
Jones64 (1990) 75% 61% _
Watters va cs.65 (1992) 74% 83% _
Okamoto va cs.66 (1994) 63% 78% 80%
Leenhardt va cs.67 (1997) 75% 83% _
Kerr5 (1994) 87% 95% 94%
Solbiati28 (1995) 77% 95% 88%
cat na tuyen do nhan lanh va phat hien c mot tnh thng co dang thon nho bau duc va thng
hay nhieu o u ac tren mau phau thuat, anh gia bieu hien mot dai trung tam co phan am tang tng
sieu am thuy oi dien con lai e loai tr mot nhan ng vi ron m cua hach (Hnh 21-11). Ngc lai,
sot. cac hach ac tnh thng tron hn do tac nghen bi
Cac hach bach huyet vung co du bnh thng tham nhiem u (Hnh 21-12). Tuy cac hach ac tnh
hay bat thng eu thay c tren sieu am phan thng co phan am giam, chung cung co the tang
giai cao. Chung co khuynh hng nam doc theo phan am lan toa. Do nhng o phan biet nh vay
chuoi canh trong, trai t xng on len goc ham khong thc ro rang, phai dung ti FNA di hng
hoac trong vung cua ho giap. Cac hach co lanh dan cua sieu am e khang nh tnh ac. Theo kinh
Hnh 21-23. Choc hut bang kim nho (FNA). Hnh cat
ngang thuy phai cua tuyen giap cho thay mot nhan (mui ten)
cha nhng vung nho dang nang. Kim (mui ten cong) c a
vao phan ac cua u ni o ket qua te bao hoc se cao hn vung
bien oi dang nang. ay la u lanh.
theo tuoi va theo gii.71 Trong so 1000 benh nhan

tang calcium mau, 410 (41%) co nhan giap thay
c tren sieu am, trong so o ch s thay 80 nhan
Hnh 21-22. Dong mau ti trong nhan cua
(8%). Mot bao cao khac mi ay cua Phan Lan
carcinoma nhu trc va sau khi tienm chat tng
cung cho thay u the cua sieu am trong viec phat
phan. A, Nhan tang phan am vi hnh thai ti mau ben
trong. B, 2 phut sau khi tiem chat tng phan qua tnh mach hien cac bat thng cua tuyen giap.50 101 phu n
(Levovist), co s gia tang mau ti trong nhan. trong nghien cu nay khong co tien s benh giap
hoac can giap, 36% thay c mot hoac nhieu
nhan giap tren sieu am. Khi mo t thi nhng ngi
nghiem cua chung toi, co the thc hien sieu am vi co tuyen giap bnh thng tren lam sang, ty le
o chnh xac cao e sinh thiet cac hach co co nhan giap phat hien co phan nao cao hn; 49,5%
ng knh 0,5 cm. co mot hoac nhieu nhan thay c.72 Nh vay, sieu
am phan giai cao dng nh phat hien phan ln
Nhan c phat hien tnh c cac nhan giap va ca hai nghien cu tren eu chng
Mac du trong mot so tnh huong, sieu am o phan to moi lien quan trc tiep gia ty le phat hien nhan
giai cao mang lai nhieu li ch khi phat hien c giap vi tuoi cua benh nhan (Hnh 21-24).
nhng nhan giap nho khong s thay c, trong Mac du cac nghien cu tren cho thay ty le phat
mot so hoan canh khac, no thc s gay ra nhieu hien nhan giap cao khi mo t thi va sieu am, ty le
van e. Ngi ta phai lam g khi phat hien c ac tnh tm thay lai thap ch t 2% en 4%, lu y
nhieu nhan trong tuyen giap mot cach tnh c trong rang a so (90%) la ung th dang nhu tiem an
khi khao sat sieu am mach canh, can giap hoac cau (<1,5 cm)(Bang 21-4).70,72 Ung th tuyen giap loai
truc khac vung co? Van e la lam sao ng qua nhu chiem khoang 90% tong so cac ung th giap
ton kem i anh gia a so benh nhan mang benh c chan oan mien Trung Tay Hoa Ky t nam
lanh tnh va cung khong bo sot thieu so benh nhan 1970.12,21 a phan cac benh nhan b ung th giap
mang ung th tuyen giap. Qua s nan lam sang, dang nhu tiem an co tien lng tot, thi gian hy
nhan giap chiem 4% en 7% dan so chung cua Hoa vong song khong giam va cung khong nhieu bien
Ky nhng sieu am phan giai cao a phat hien nhan chng khi phau thuat thch hp. Nhieu bang chng
giap trong khoang 40% quan the co calcium mau khac chng to ung th giap khong bieu hien lam
tang.8,70 Cac nghien cu trc ay cho thay cac sang thng mang benh s t nhien lanh tnh da
benh nhan b cng can giap khong co thong ke ve vao xuat o phat hien ung th giap hang nam ch
nhan giap cao hn so vi kiem chng mo t thi vao khoang 0,005% (5 trong so 100.000 ngi).12,21
Tuyen Giap 723
Hnh 21-24. So sanh ty le phat hien cac nhan giap qua mo t thi va sieu am. Mo
t thi, dau tron en, trung bnh 49% vao nam 1955. Sieu am, dau tron trang, trung bnh 41% vao
nam 1985, oi chieu theo tuoi benh nhan. (Chnh sa t Horlocker TT, Hay JE, Kames EM va
cs. Ty le phat hien tnh c cac nhan giap trong khi sieu am phan giai cao tuyen can giap. Trong:
Medeiros-Neto C, gaitan E, eds. Frontier in Thyroidology, vol.2. New York: Plenum Medical
Book Co; 1986.)
BANG 21-4
TY LE PHAT HIEN NHAN GIAP
ANH GIA CAC NHAN PHAT HIEN TNH C
Phng phap phat hien Benh nhan (%) BANG SIEU AM
Mo t thi 49
Sieu am 41 Nhan di 1,5 cm
S nan 7
Theo doi bang s nan vao lan kham ke tiep
Ung th tiem an (mo t thi) 2
Xuat o ung th (hang nam) 0,005 Nhan tren 1,5 cm
anh gia (thng bang FNA)
Nhan mang ac tnh ac tnh
anh gia bang FNA
Neu gan 50% dan so Hoa Ky c khao sat
sieu am va tm ra bang chng m ho cua benh
tuyen giap, ty le xuat o hang nam cua carcinoma
giap co lam sang ro ret ch chiem khoang 0,005%, khao sat e anh gia (thng la FNA), du tnh chat
ro rang la ch mot thieu so nho nhng benh nhan vat ly va sieu am nh the nao. Nhan di 1,5 cm
mang nhan giap co nguy c b ung th giap ro ret co the c theo doi qua s nan khi tai kham lan
tren lam sang (Bang 21-4). Ngoai ra, neu 90% so ke tiep.73
ung th nay thuoc loai nhu va nh vay ieu tr Hnh anh sieu am. Cac nhan mang cac ac
c sau khi hien ro tren lam sang, dng nh eu tnh cua nhan ac (ong voi li ti, ng b khong
khong thc te va khong than trong neu i lam chan eu, halo day, hnh thai dong mau ben trong) phai
oan tat ca nhng nhan nho phat hien tnh c bang c khao sat tiep bang FNA di hng dan cua
sieu am phan giai cao. sieu am (Hnh 21-19).74
V the, oi vi nhng nhan khong s thay ma Trong phan ln cac trng hp nhan phat hien
ch c phat hien tnh c tren sieu am, hai tieu tnh c, chung toi khuyen ch can theo doi n gian
chuan hnh anh hoc sau ay dung e xac nh s bang tham kham s nan co khi tai kham. Theo kinh
can thiet cua viec tiep tuc lam chan oan. nghiem cua chung toi, theo doi khao sat sieu am,
Kch thc. a so cac nhan vt qua 1,5 cm xa hnh, FNA, phau thuat lay bo cac nhan nh the
oi vi ng knh ln nhat phai c lam them hiem khi can thiet.
BENH LAN TOA CUA TUYEN GIAP

BENH LAN TOA CUA TUYEN GIAP
Nhieu benh cua tuyen giap mang tnh chat lan toa
hn khu tru. ieu nay lam cho tuyen ln ra (phnh Viem tuyet giap sinh mu cap tnh
giap) va khong co nhan s thay. Mot so ieu kien Viem tuyen giap dang hat ban cap
ac biet thng gay ra tnh trang ph ai lan toa Viem tuyen giap Hashimoto (dang lympho man tnh)
Phnh giap tuyen hoac keo
nay bao gom viem giap man dang lympho do t
Viem tuyen giap khong au (tham lang)
mien (Hashimotos), phnh giap tuyen hoac keo, Benh Grave
va benh Grave. Chan oan cac tnh trang nay Viem tuyen giap x hoa xam lan
thng can ti cac dau hieu lam sang va xet
nghiem va oi khi bang FNA. t khi co ch nh
sieu am. Mot tnh huong lam sang can ti sieu am
phan giai cao la khi benh lan toa lam ph ai tuyen bnh thng (Hnh 21-26, A).78 Cac vach x lam
khong oi xng, khien nghi ng hien dien cua u cho nhu mo tr nen gia a thuy (Hnh 21-26, B).
trong thuy ln hn. Cac dau hieu sieu am cua bat Nhieu nhan nho li ti kho thay vi kch thc 1 en
thng nhu mo lan toa se canh bao cho bac s lam 6 mm hien len cang cung co chan oan viem tuyen
sang ve mot nguyen nhan tiem an. FNA di giap man (Hnh 21-26, C). Ve mat mo hoc, chung
hng dan cua sieu am, neu can, c thc hien bieu hien nhng tieu thuy cua nhu mo a b tham
neu phat hien c mot nhan. Nhan nh ph ai nhiem bi te bao lympho va tng bao. Nhng tieu
tuyen lan toa tren sieu am da vao o day cua eo. thuy nay co cac dai si tang phan am bao quanh.
Bnh thng, o la mot cau mo mong co ng Tao hat nho la dau hieu co o nhay cao cho chan
knh trc sau ch vai mm. Khi tuyen ph ai lan oan viem giap man vi gia tr d oan dng la
toa, o day cua eo co the ti 1 cm hoac hn. 94,7%.78 Ca nhan giap lanh va ac eu co the ket
Co nhieu loai viem tuyen giap khac nhau bao hp vi viem giap man dang lympho va can FNA
gom viem giap sinh mu cap tnh, viem giap dang e co c chan oan sau cung.79 oi khi, giau
hat ban cap (con goi la benh Quervain) va viem mach mau giong nh dang thyroid inferno cua
giap man dang lympho (con goi la benh benh Grave (Hnh 21-26, D). Mot nghien cu gan
Hashimoto).75 Moi benh co ac tnh lam sang va ay cho rang tang mau ti xay ra khi giam nang
xet nghiem khac nhau. Viem giap sinh mu cap giap phat trien.80 Hach ph ai t gap hn, neu co,
tnh la mot benh ly viem hiem gap thng do thng gap hach Delphian pha tren eo giap. Giai
nhiem vi trung. Sieu am co the ch li trong mot so oan cuoi cua viem giap man la tuyen nho i, teo
trng hp e phat hien ap xe. Viem giap dang lai vi ng b khong ro net va cau truc tr nen
hat ban cap la mot benh viem co the khoi t tho do x hoa tang dan. Cac tn hieu ti mau
nhien nhieu kha nang do tac nhan virus. Dau hieu khong con thay. oi khi, xuat hien mot so nhan m
lam sang gom sot, ph ai tuyen va au khi s nan. ho va can lam FNA e chan oan.79
Tren sieu am, tuyen ln len va giam phan am so Viem tuyen giap khong au (tham lang) co
vi bnh thng hoac giam mau ti do phu lan toa hnh thai mo hoc va sieu am cua viem giap man t
trong tuyen.50,76,77 Thng khong can thiet nhng mien (giam phan am, nhieu hat nho va x hoa)
sieu am cung c dung e theo doi dien tien nhng dau hieu lam sang giong nh viem giap ban
benh sau khi ieu tr noi khoa (Hnh 21-25). cap kinh ien ngoai tr hach khong au. Cng
Loai viem giap thng gap nhat la viem giap giap trung bnh kem ph ai tuyen giap xay ra
man tnh dang lympho do t mien (benh trong giai oan sm, oi khi i kem giam nang
Hashimoto). ien hnh no xay ra di dang ph giap vi nhieu mc o. Viem giap hau san thng
ai tuyen giap lan toa phu n tre hoac trung dan ti giam nang giap hn. Trong a so cac
nien, khong au, thng kem vi giam nang tuyen trng hp, benh t khoi sau 3 en 6 thang va
giap. Hnh anh sieu am ien hnh cua benh tuyen co the tr lai hnh thai bnh thng.
Hashimoto la ph ai tuyen lan toa, ong nhat Mac du hnh anh cau truc nhu mo khong ong
nhng hi tho, co phan am giam hn nhu mo giap nhat va nhieu hat la ien hnh cua viem tuyen giap
Hashimoto , cac benh ly lan toa khac cua tuyen
Tuyen Giap 725
Hnh 21-25. Ton thng khu tru trong viem tuyen giap ban cap. A, Hnh cat doc cho
thay mot vung giam phan am, khong gii han ro (mui ten). B, Sau 4 tuan ieu tr noi khoa, tuyen
giap tr ve bnh thng.
Hnh 21-26. Cac hnh thai khac nhau cua viem tuyen giap Hashimoto. A, Tuyen
giap ph ai va giam phan am. B, Hnh thai gia a thuy va hien dien nhng dai x tho. C,
Nhieu not nho phan am kem. D, Tr6n Doppler mau cho thay gia tang mach mau.
Hnh 21-27. Phnh gap lan toa. A, Hnh cat ngang cho
thay vung eo va ca hai thuy ph ai lan toa ma khong co not
khu tru. B va C, Hnh cat doc qua thuy phai va thuy trai
tuyen giap; mot benh nhan khac cho thay tuyen khong ong
nhat vi nhieu hat nho.
Hnh 21-28. Benh Grave. A, Hnh cat doc cho thay nhu mo tuyen khong ong nhat. B,
Doppler mau cho thay tang mach mau lan toa. C, Doppler pho cho thay van toc nh tam thu la
80 cm/giay. D, Sau ieu tr noi khoa, o ti mau va van toc nh tam thu tr ve bnh thng.
Tuyen Giap 727
giap, nhat la phnh giap dang tuyen, cung co the THAM KHAO
co hnh thai tng t. Mot vai benh nhan b phnh Giai phau
1. Rogers WM. Anomalous development of the thyroid. In:
giap dang tuyen co nhieu not nho m ho ngan cach Werner SC Ingbar SH, eds. The Thyroid. New York:
nhau bi nhu mo giap bnh thng; mot so khac b Harper& Row: 1978:416-420.
ph ai tuyen vi cac cc tren va di phnh tron, 2. Toma P, Guastalla PP, Carini C, Lneigrai G. [Collo] In:
Fariello G, Perale R, Perri G, Toma P, eds. Ecografia
nhu mo khong ong nhat va khong phan biet c Pediatrica. Milano: Ambrosiana; 1992:139-162.
vi nhu mo bnh thng (Hnh 21-27). 3. Solbiati L. La tiroide e learatiroidi. In: Rizzatto G,
Solbiati L, eds. Anatomia Ecografica: Quadri Normali,
Benh Grave la mot bat thng lan toa thng
Varianti e Limiti con il Pato- logico. Milano: Masson;
gap tuyen giap va ac trng ve mat sinh hoa la 1992:35-45.
s gia tang chc nang (nhiem oc giap). Cau truc 4. Jarloy AE, Hegedus L, Gjorup T, Hansen JEM. Accuracy
of the clinical assessment of thyroid size. Dan Med Bull
phan am khong ong nhat nhieu hn so vi phnh
1991;38:87-89.
giap lan toa, chu yeu do s hien dien cua nhieu 5. Kerr L. High-resolution thyroid ultrasound: the value
mach mau ln ben trong tuyen. Ngoai ra, ac biet of color Doppler. Ultrasound Quart 1994;12:21-43.
6. Yokoyama N, Nagayama Y, Kakezono F et al.
benh nhan tre, nhu mo co the giam phan am lan Determination of the volume of the thyroid gland by
toa do tham nhiem te bao lympho lan rong hoac v a high-resolutional ultrasonic scanner. J Nucl Med
thanh phan te bao trong nhu mo b mat chat keo. 1986;27:1475-1479.
7. Ueda D, Mitamura R, Suzuki N et al. Sonographic
Khao sat Doppler mau thng cho thay hnh thai imaging of the thyroid gland in congenital
tang mach mau tng ng vi cai goi la thyroid hypothyroidism. Pediatr Radiol 1992; 22: 102-105.
inferno. Doppler pho thng cho thay van toc Benh giap nhan
nh tam thu vt qua 70 cm/giay, tc van toc cao 8. Rojeski MT, Gharib H. Nodular thyroid disease:
evaluation and management. N Engl J Med 1985;313:428-
nhat gap trong benh cua tuyen giap. Khong co s 236.
tng quan gia mc o tang nang giap o c t 9. 9an Herle AJ, Rich P, Ljung B-ME et al. The thyroid
nodule. Ann Intern Med 1992;96:221-232.
cac xet nghiem sinh hoa vi o lan rong cua tnh
10. ``Favus MJ, Schneider AB, Stachura ME et al. Thyroid
trang tang mach mau hoac van toc dong mau. Cac cancer occurring as a late consequence of head-and-neck
nghien cu gan ay cho thay co the s dung phan irradiation: evaluation of 1056 patients. N Engl J Med
1976:294:1019-1025.
tch Doppler e theo doi ap ng ieu tr benh 11. Degroot LJ, Reilly M, Pinnameneni K et al.
nhan b benh Grave.81 Ngi ta nhan thay sau khi Retrospective and prospective study of radiation-induced
ieu tr noi khoa, cac van toc dong ong mach thyroid disease. Am J Med 1983:74:852-862.
12. Grebe SKG, Hay ID. Follicular cell-derived thyroid
giap tren va giap di eu giam. carcinoma. In: Arnold A. ed. Cancer Treatment and
Loai hiem nhat cua benh ly viem tuyen giap la Research. EndocrineNeoplasms. Norwell, Mass.: Kluwer
viem giap x hoa xam lan, con goi la bu giap Academic; 18:91-140.
13. Hennemann G. Non-toxic goitre. Clin Endocrinol Metab
Riedel.75 Benh nay anh hng phu n va thng 1979; 8: 167-179.
co khuynh hng phat trien mot cach khong lng 14. Solbiati L, Cioffi V, Ballarati E. Ultrasonography of
the neck. Radiol Clin North Am 1992;30:941-954.
lam pha huy toan bo tuyen. Mot vai trng hp ket
15. Muller HW, Schroder S, Schneider C, Seifert G.
hp vi x hoa trung that hoac sau phuc mac hoac Sonographic tissue characterization in thyroid gland
viem x cng ng mat. Trong vai trng hp co diagnosis. Klin Wochenschr 1985:63:706-710.
khao sat sieu am, tuyen ln lan toa va cau truc nhu 16. Lagalla R, Caruso G, Midiri M, Cardinale AE. Echo
Doppler-couleur et pathologic thyroidienne. JEMU 1992;
mo khong ong nhat. Ly do chnh phai khao sat 13:44-47.
sieu am la kiem tra s lan rong ngoai giap cua qua 17. Solbiati E, Ballarati E, Cioffi V. Contribution of
color- How mapping to the differential diagnosis of
trnh viem co the boc quanh cac mach mau co.
the thyroid nodules [abstract] Presented at Radiological
Nhng thong tin nay rat can thiet cho viec hoach Society of North America Meeting 1991.
nh phau thuat. Thng can sinh thiet m e phan 18. 18. Solbiati E, Volterrani E, Rizzatto G et al. The thyroid
gland with low uptake lesions: evaluation by
biet tnh trang nay vi carcinoma giap giam biet ultrasound. Radiology 1985; 155:187-191.
hoa. Cac dau hieu sieu am trong hai benh nay co 19. Ahuja A, Chick W, King W, Metreweli C. Clinical
the giong het nhau. significance of the comet-tail artifact in thyroid ultrasound.
J Clin Ultrasound 199624:129-133.
20. Eagalla R. Caruso G, Cardinale AE. Analisi
flussimetrica nelle malattie tiroidee: ipotesi di integrazione
con lo studio qualitativo con color-Doppler. Radiol Med
1993;85:606-610.
21. Hay ID. Thyroid cancer. Curr Ther Int Med 1991:3:931-935. 42. Khafagi F, Wright G, Castles H et al. Screening for
22. Black BM, Kirk TA Jr, Woollier EB. Multicentricity of thyroid malignancy: the role of fine-needle biopsy. Med J
papillary adenocarcinoma of the thyroid: influence on Aust 1988;149:302-303, 306-307.
treatment. J Clin Endocrinol Metab 1960:20:130-135. 43. Hall TL, Layfield LJ, Philippe A et al. Sources of
23. McConahey WM, Hay ID, Wollner EB et al. Papillary diagnostic error in fine-needle aspiration of the thyroid.
thyroid cancer treated at the Mayo Clinic, 1946 Cancer 1989;63:718-725.
through 1970: initial manifestations, pathologic findings, 44. Altavilla G, Pascale M, Nenci I. Fine-needle aspiration
therapy, and outcome. Mayo Clin Proc 1986:61:978-996. cytology of thyroid gland diseases. Acta Cytol 1990,34:251-
24. Pilotti S, Pierotti MA. Classificazione istologica e 256.
caratterizzazione molecolare dei tumori del epitelio 45. Ravetto C, Spreafico GL, Colombo L. Lesame citologico
follicolare della tiroide. Argomenti di Oncologia con ago- aspirato nella diagnosi precoce delle neoplasie
1992:13:365-380. tiroidee. Rec Progr Med 1977,63:258-267.
25. Holtz S, Powers WE. Calcification in papillary 46. James EM, Charboneau JW. High-frequency (10 MHz)
carcinoma of the thyroid. Radiology 1958;80:997-1000. thyroid ultrasonography. Semin Ultrasound, CT, MR
26. 26. Brkljacic B, Cuk V, Tomic-Brzac H, Bence-Zigman 1985:6:294-309.
Z, Delic-Brkljacic D, Drinkovic I. Ultrasonic 47. Scheible W, Leopold GR. Woo VL et al. High-resolution
evaluation of benign and malignant nodules in real-time ultrasonography of thyroid nodules. Radiology
echographically multinodular thyroids. J Clin Ultrasound 1979;133:413-417.
1994;22:71-76.
48. Simeone JF, Daniels GH, Mueller PR et al. High-
27. Solbiati E, Ballarati E, Cioffi V. Contribution of color- resolution real-time sonography of the thyroid. Radiology
flow mapping to the differential diagnosis of the thyroid 1982;145:431-435.
nodules [abstract] Presented at Radiological Society of 49. Brown CL. Pathology of the cold nodule. Clin Endocrinol
North America Meeting 1990. Metab 1981;10:235-245.
28. Solbiati L, lerace T, Lagalla R et al. Reliability of high-
50. Brander A, Viikinkoski P, Nickels J et al. Thyroid
frequency US and color Doppler US of thyroid nodules:
gland: US screening in middle-aged women with no
Italian multicenter Study of 1,042 pathologically
previous thyroid disease. Radiology 1989;173:507-510.
confirmed cases. Which role for Scintigraphy and
51. Hay ID. Papillary thyroid carcinoma. Endocrinol Metab
biopsy? [abstract] Presented at Radiological Society of
Clin North Am 1990;19:545-576.
North America Meeting 1995.
52. Hay ID, Reading CC, Weiland LH et al.
29. Solbiati L, Livraghi T, Ballarati E et al. Thyroid gland. In:
Clinicopathologic and high-resolution ultrasonographic
Solbiati L, Rizzatto G, eds. Ultrasound of superficial
evaluation of clinically suspicious or malignant thyroid
structures. Edinburgh: Churchill Livingstone;1995:49-85.
disease. In: Medeiros-Neto G, Gaitan E, eds. Frontiers in
30. Chong GC, Beahrs OH, Sizemore GW et al. Medullary
Thyroidology, vol. 2. New York: Plenum Medical Book
carcinoma of the thyroid gland. Cancer 1975,35:695-704.
Co- 1986.
31. German B, Charboneau JW, James EM et al. Medullary
53. Simeone JF, Daniels GH, Hall DA et al. Sonography in the
thyroid carcinoma: role of high-resolution ultrasound.
follow-up of 100 patients with thyroid carcinoma. AJR
Radiolog y 1987, 162:147-150.
1987;148:45-49.
32. Nel CJC, van Heerden JA, Goellner JR et al. Anaplastic
54. Button RT, Reading CC, Charboneau JW et al. Ultrasound-
carcinoma of the thyroid: a clinicopathologic study of 82
guided biopsy of neck masses in postoperative management
cases. Mayo Clin Proc 1985,60:51-58.
of patients
33. Hamburger JI, Miller JM, Kini SR. Eymphoma of the
55. with thyroid cancer. Radiology 1988;168:769-772. ,
thyroid. Ann Intern Med 1983;99:685-693.
56. 55. Katz JF, Kane RA, Reyes J et al. Thyroid nodules:
34. Kasagi K, Hatabu H, Tokuda Y et al.
sonographic-pathologic correlation. Radiology
Lymphoproliferative disorders of the thyroid gland:
1984;151:741-745.
radiological appearances. Br J Radiol 1991;64:569-575.
57. Hammer M, Wortsman J, Folse R. Cancer in cystic
35. Takashima S, Morimoto S, Ikezoe et al. Primary
lesions of the thyroid. Arch Surg 1982; 117:1020-1023.
thyroid lymphoma: comparison of CT and US assessment.
58. Propper RA, Skolnick ML, Weinstein BJ et al. The
Radiology 1989; 171:439-443.
nonspecificity of the thyroid halo sign. J Clin Ultrasound
36. Feld S, Barcia M, Baskic HJ et al. AACE clinical practice 1980,8:129-132.
guidelines for the diagnosis and management of thyroid
59. Takashima S, Fukuda H, Kobayashi T. Thyroid nodules:
nodules. Endocr Pract 1996,2:78-84.
clinical effect of ultrasound-guided fine-needle aspiration
37. Miller JM. Evaluation of thyroid nodules: accent on needle biopsy. J Clin Ultrasound 1994,22:535-542.
biopsy. Med Clin North Am 1985;69:1063-1077.
60. Fobbe F, Finke R, Reichenstein E et al. Appearance of
38. Hamberger B, Gharib H, Melton IJ III et al. Fine-needle thyroid diseases using colour-coded duplex sonography.
aspiration biopsy of thyroid nodules: impact on thyroid Eur J Radiol 1989: 9:29-31.
practice and cost of care. Am J Med 1982,73:381-384.
61. Argalia G, D'Ambrosio F", Lucarelli et al. L' eco color
39. Goellner JR, Gharib H, Grant CS et al. Fine-needle Doppler nella caratterizzazione della patologia nodulare
aspiration cytology of the thyroid, 1980 to 1986. Acta Cytol tiroidea. Radiol Med 1995:89:651-657.
1987;31:587-590.
62. Spiezia S, Colao A, Assanti AP et al. Utilita de l
40. 40. Gharib H, Goellner JR. Fine-needle aspiration eco color Doppler con power Doppler nella diagnostica
biopsy of the thyroid: an appraisal. Ann Intern Med 1993;! dei noduli tiroidei ipoecogeni: work in progress. Radiol
18:282-289. Med 1996; 91:616-621.
41. Hawkins F, Bellido D, Bemai C et al. Fine-needle
63. Clark KJ, Cronan JJ, Scola FH. Color Doppler
aspiration biopsy in the diagnosis of thyroid cancer and
sonography: anatomic and physiologic assessment of
thyroid disease.Cancer 1987;59:1206-1209.
the thyroid. J Clin Ultrasound 1995,23:215-223.
Tuyen Giap 729
64. Shimamoto K, Endo T, Ishigaki T et al. Thyroid 74. Mortensen JD, Woolner LB, Bennett WA. Gross and
nodules: evaluation with color Doppler microscopic findings in clinically normal thyroid glands.
ultrasonography. J Ultrasound Med 1993; 11:673-678. J Clin Endocrinol Metab 1955;15:1270-1280.
65. Jones AJ, Aitman TJ, Edmonds CJ et al. Comparison of 75. Giuffrida D, Gharib H. Controversies in the management
fine-needle aspiration cytology, radioisotopic and of cold, hot, and occult thyroid nodules. Am J Med
ultrasound scanning in the management of thyroid nodules. 1995:99:642-650.
Postgrad Med J 1990;66:914-917. 76. Tan GH, Gharib H, Reading CC. Solitary thyroid nodule:
66. Watters DAK, Ahuja AT, Evans RM et al. Role of comparison between palpation and ultrasonography. Arch
ultrasound in the management of thyroid nodules. Am J Intern Med1995;155:2418-2423.
Surg 1992;164:654-657.
Benh lan toa cua tuyen giap
67. Okamoto T, Yamashita T, Harasawa A et al. Test
77. Hay ID. Thyroiditis: a clinical update. Mayo Clin Proc
performances of three diagnostic procedures in evaluating
1985; 60:836-'843.
thyroid nodules: physical examination, ultrasonography and
78. Adams H, Jones NG. Ultrasound appearances of de
fine-needle aspiration cytology. Endocr J 1994;41:243-247.
Quervain's thyroiditis. Clin Radiol 1990;42:217-218.
68. Leenhardt L, Tramalloni J, Aurengo H et al.
79. Birchall IWJ, Chow CC, Metreweli C. Ultrasound
Echographie des nodules thyroidiens: Pechographiste
appearances of de Quervain's thyroidits. Clin Radiol
face aux exigences du clinicien . Presse-Med
1990;41:57-59.
1994,23:1389-1392.
80. Yeh HC, Futterweit W, Gilbert P. Micronodulation:
69. Quinn SF, Nelson HA, Demlow TA. Thyroid biopsies:
ultrasonographic sign of Hashimoto's thyroiditis. J
fine-needle aspiration biopsy versus spring-activated core
Ultrasound Med 1996; 15:813-819.
biopsy needle in 102 patients. JVIR 1994,5:619-623.
81. Takashima S, Matsuzuka F, Nagareda T et al. Thyroid
70. Taki S, Kakuda K, Kakuma K et al. Thyroid nodules:
nodules associated with Hashimoto's thyroiditis:
evaluation with US-guided core biopsy with an automated
assessment with US. Radiology 1992;185:-125-130.
biopsy gun. Radiology 1997;202:874-877.
82. Uagalla R, Caruso G, Benza I et al. Echo-color Doppler
71. Horlocker TT, Hay JE, James EM et al. Prevalence of
in the study of hypothyroidism in the adult. (Ital)
incidental nodular thyroid disease detected during high-
Radiol Med 1993; 86:281-283.
resolution parathyroid ultrasonography. In: Medeiros-
Neto G, Gaitan E, eds. 83. Gastagnone D, Rivolta R, Rescalli S et al . Color Doppler
72. Frontiers in Thyroidology, vol. 2. New York: Plenum sonography in Graves' disease: value in assessing
Medical Book Co; 1986:1309-1312. activity of disease and predicting outcome. AJR
1996;166:203-207.
73. Lever EG, Refetoff S, Straus FH II et al. Coexisting
thyroid and parathyroid disease: are they related? Surgery
1983;94:893-900.
C H N G 2 2
Tuyen can giap

C. Richards Hopkins, M.D.
Carl C. Reading, M.D.
D A N B A I
PHOI THAI HOC VA GIAI PHAU HOC Adenoma trong trung that
CNG CAN GIAP NGUYEN PHAT Adenoma trong tuyen giap
Xuat o Adenoma khong xuong/ trong bao canh
Chan oan CUNG CAN GIAP TON TAI HOAC TAI PHAT
Benh hoc CNG CAN GIAP TH PHAT
ieu tr LY GIAI CAC ANH GIA
HNH ANH SIEU AM Kham nghiem dng tnh gia
Hnh dang Kham nghiem am tnh gia
Tnh phan am TNH CHNH XAC
Cau truc ben trong Sieu am
Kch thc Cac phng thc chan oan hnh anh khac
Benh a o cua tuyen Ban luan: co s dung chan oan hnh anh hay
Carcinoma khong trong cng can giap nguyen phat
V TR CUA U TUYEN SIEU AM TRONG LUC MO
Cach kham sieu am SINH THIET QUA DA
Cac v tr ien hnh HUY U BANG CON
Cac v tr lac cho
Adenoma sau kh quan
Sieu am tan so cao la phng phap chan oan huy u bang con qua da nh la mot lieu phap thay
hnh anh khong xam nhap, ang tin cay dung e the cho phau thuat.
anh gia cac benh tuyen can giap. Sieu am c
s dung thng nhat e anh gia chnh xac trc PHOI THAI HOC VA GIAI PHAU HOC
mo v tr cac tuyen can giap to ra benh nhan
cng can giap. No con hng dan sinh thiet qua Cac oi can giap tren va di co nguon goc
da trong trng hp nghi ng u tuyen tuyen can phoi thai khac nhau, hieu ro s phat trien cua
giap, ac biet trong boi canh cng can giap tai chung giup ta biet c can ban cac v tr giai phau
phat hay keo dai va giup nh v trong mo cac hoc1-3. Cac tuyen can giap tren xuat phat t tui
trng hp co bat thng tuyen can giap. Mot so khe mang th t. Chung di chuyen rat t trong qua
adenoma can giap co chon loc, sieu am hng dan trnh phat trien phoi thai va nam nh vao mat sau
khoang gia-tren cua tuyen giap. a so cac trng

hp (80%) khi mo t thi , cac tuyen can giap tren
c tm thay trong pham vi 2 cm tren cho bat
cheo cua than kinh quat ngc thanh quan vi
ong mach giap di4. Cac tuyen can giap di
xuat phat t tui khe mang th ba, i doc theo tuyen
c.2 Trong qua trnh phat trien phoi thai, cac
tuyen can c nay di chuyen xuong di theo
tuyen c tren mot ng nam trc hn so vi
cac tuyen can giap tren va bat cheo qua chung e
tr thanh cac tuyen can giap di.3 Cac tuyen di
nay co v tr thay oi hn so vi cac tuyen tren
nhng thng (tren 60%) nam tai hay ngay di
cc di tuyen giap (Hnh 22-1).4 Khoang 25%
trng hp cac tuyen can giap di khong tach ra
vi tuyen c va se tiep tuc di chuyen xuong thap
hn, trong mo vung co hay trong trung that, thng
nam trong day chang c-giap.
Co mot t le co y ngha cac tuyen can giap lac
cho that s hay tng oi vung co hay trong trung
that. Cac tuyen can giap di thng nam lac cho
hn. Chung thng nam oi xng nhau qua nhng
moc co nh trong 70-80% cac trng hp khi so
sanh ben-ben.3,4 Tuyen can giap tren lac cho
thng nam xa ve pha sau trong ranh kh-thc
quan hay phnh to ra va tiep tuc i xuong trong
H.22-1. Tan suat cua v tr cac tuyen can giap tren va
phan co sau vao trung that sau-tren.5,6 t khi tm
di bnh thng t 527 trng hp mo t thi; hnh hoa giai
thay cac tuyen can giap tren phan cao cua co phau. T, Tuyen giap. (theo Gilmour JR. The gross anatomy of
hay gan phan tren cua thuy tuyen giap va hiem khi the parathyroid glands. J Pathol 1938;46:133-148.)
thay chung nam trong nhu mo trong bao tuyen
giap4. Khi b lac cho, cac tuyen can giap di
thng tiep tuc i xuong theo hng trc-di
nam trong phan thap cua co hay trong trung that
trc-tren theo tuyen c. Hiem khi v tr lac cho
cua tuyen can giap di nam phan cao cua co do
khong i xuong theo tuyen c, gan cho chia ong nay thng i kem vi tuyen c trong trung that
mach canh hay thap hn doc theo bao canh.7 Hiem trc, gi len moi tng quan trong qua trnh phat
hn, vai bao cao cac tuyen lac cho c tm thay trien cua chung.11
thap hn trong trung that nh trong ca so phe-chu, Mau tuyen can giap bnh thng thay oi t
sau cho chia kh quan, sau thc quan, trong mang vang en vang-nau tuy thuoc vao so lng m
tim hay trong tam giac co sau. vang trong nhu mo va thanh phan te bao chnh. No
Hau het ngi trng thanh co bon tuyen can thng co dang hat au hay bau duc, nhng cung
giap (hai tren va hai di), kch thc moi chieu la co the co dang hnh cau, hnh thoi dai hay dang
5 mm, 3 mm va 1 mm, vi trong lng trung bnh nhieu thuy. oi khi nhn thay c tuyen can giap
khoang 35 en 40 mg (thay oi t 10 en 78 mg).3,8 bnh thng tren sieu am tan so cao, ac biet la
Tuyen phu th nam gap tren 13% dan so 3 va la ngi tre, nhng khi nhn thay mot tuyen can giap
hau qua cua s phan chia cac nhanh phu cua tuyen bnh thng tren sieu am benh nhan khong co
can giap khi chung i ra khoi cau truc tui trong giai hoi chng cng can giap th khong co ch nh
oan phc hp khe mang phoi thai.9,10 Tuyen phu phau thuat.12
Tuyen can giap 733
CNG CAN GIAP NGUYEN PHAT

CAC NGUYEN NHAN CUA CNG CAN
Xuat o
GIAP NGUYEN PHAT
Cng can giap nguyen phat hien nay la mot benh
noi tiet pho bien, tan xuat My la 100 en 200 Adenoma n oc 80%-90%
tren 100.000 dan.13 Phu n mac benh nhieu gap hai Phnh to tuyen nhieu cho 10%-20%
en ba lan nam gii, ac biet sau tuoi man kinh. Carcinoma < 1%
Hn na so benh nhan mac benh co o tuoi tren 50
va rat hiem xay ra trc 20 tuoi.
Chan oan
Nghi ng b cng can giap khi nong o canxi benh hoc cung kho phan biet tang san vi u tuyen
huyet thanh tang cao c phat hien tren xet a o, cho nen ca hai nhom nay cung c xem ve
nghiem sinh hoa thng qui. Giam phosphat hay mat mo hoc la benh tuyen nhieu ni.17
tang canxi nieu cung la dau hieu sinh hoa cua Ph ai tuyen can giap nhieu ni xay ra tren
benh. Nong o hormone can giap (parathyroid 90% benh nhan co a u tan sinh noi tiet, typ I
hormone=PTH) trong huyet thanh thng cao (MEN I).18,19 ay la mot ac iem di truyen theo
khong tng thch vi nong o canxi huyet thanh autosom troi t gap, co o xam nhap cao va gay ra
thong thng giup xac nh chan oan. Ngay ca khi tnh trang tang san can giap dang tuyen
nong o PTH gii han cao cua mc bnh thng (adenomatous parathyroid hyperplasia). a so
tren mot benh nhan co tang canxi mau, chan oan benh nhan MEN I eu co tang canxi mau trc o
cng can giap van nen at ra, v tang canxi mau tuoi 30 hay 40. Mac du khong phai tat ca cac tuyen
do cac nguyen nhan ngoai can giap co the c che can giap eu phnh to ra ro ret cung mot luc lan
chc nang cua tuyen va lam giam nong o PTH phau thuat au tien cua nhng benh nhan MEN I,
huyet thanh. Do phat hien benh sm da vao cac nhng cuoi cung th dng nh tat ca chung eu co
xet nghiem labo thng qui nen cac dau hieu kinh lien quan en hien tng tang sinh.
ien muon nh au xng, soi than, tc bung, roi Carcinoma hiem khi gay ra cng can giap
loan tam than thng cha xay ra. Hau het benh nguyen phat. Ve mat mo hoc, kho phan biet c
nhan cha co bieu hien tram trong cua cng can mot cach chac chan gia carcinoma va adenoma v
giap nh soi than, loang xng, tieu xng di ca hai loai carcinoma va adenoma khong ien hnh
mang xng va viem xng x nang. Tuy nhien, eu co hoat ong gian phan va khong ien hnh ve
vai trieu chng m ho khong ac hieu nh moi c, mat te bao.20 Chan oan thng c at ra trong
gay sut, tao bon, kho tieu, uong nhieu va tieu khi phau thuat benh nhan co nong o canxi mau
nhieu thng c tm thay neu hoi benh ky hn cao (> 14 mg/dl), phau thuat vien thay c mot
nhng benh nhan khong co trieu chng. tuyen x, ran, phnh to dnh vi mo xung quanh do
xam lan tai cho.21-24 Thng thay no co mot bao
Benh hoc x, day. ieu tr bang cach cat tron khoi khong
Cng can giap nguyen phat do adenoma n oc lam v vo bao e phong nga gieo rac, nhng
chiem 80% en 90% cac trng hp, do ph ai trong nhieu trng hp ieu nay khong the thc
nhieu tuyen chiem 10% en 20% va do carcinoma hien c do ban chat xam lan va di can cua ung
ch di 1% (xem khung ben).14,15 Adenoma n th. Thng t vong khong phai do ung th lan tran
oc co the xay ra bat ky v tr nao trong bon ma la do nhng bien chng i kem cua tnh trang
tuyen can giap vi t le ngang nhau.16 Ph ai nhieu cng can giap khong thuyen giam.16
tuyen hau het la do tnh trang tang sinh can giap
nguyen phat, hiem khi do adenoma a o. Hien ieu tr
tng tang sinh thng xay ra khong oi xng ca nhng benh nhan co trieu chng cua cng can
bon tuyen trong khi adenoma a o thng xay ra giap nguyen phat, ieu tr c chon la la cat bo
hai tuyen, co khi ba tuyen. V s trai ngc nhau bang phau thuat mot hay nhieu tuyen can giap b
ve v tr tuyen b ton thng va v ngay ve mat ton thng. Con vai tranh luan quanh van e benh
Hnh 22-2. Adenoma can giap ien hnh. A cat ngang va, B cat doc qua mot adenoma hnh
bau duc ien hnh (mui ten) nam canh mat sau tuyen giap, T. Tr, kh quan; C, ong mach canh
chung.
nhan khong co trieu chng nhng co tang canxi a bao cao bon trng hp lipoadenoma tuyen can
mau nhe th nen ieu tr phau thuat hoac theo doi giap hiem gap co o phan am day hn mo tuyen
bang noi khoa vi kiem tra thng xuyen chc giap ke can do chung co mat o m cao.33
nang than, mat o xng, va nong o canxi huyet
thanh. mot khao sat tien cu, theo doi lam sang CAU TRUC BEN TRONG
147 benh nhan khong co trieu chng c chan ai a so cac adenoma can giap la mo ac ong
oan tam thi la cng can giap va nong o canxi nhat Khoang 2% co cau truc nang ben trong do
mau di 11 mg/dl, co 20% benh nhan can c thoai hoa nang (thng gap nhat) hay la nang that
phau thuat trong vong 5 nam, do tien trien cua s (hiem hn) (Hnh 22-3).32,34-36 Hiem khi co o voi
benh.25,26 Nhng khao sat khac cho thay rang t le hoa ben trong cac adenoma. Doppler mau trong
thanh cong khi phau thuat cua nhng phau thuat trng hp phnh to tuyen can giap cho thay co
vien co kinh nghiem la tren 95% va t le t vong, t hien tng tang ti mau chu yeu dong tam trng
le mac benh tr lai rat thap.16,27 Do o, ieu tr (Hnh 22-4). Mot cung mach mau bao quanh khoi
ngoai khoa ngay nay thng c khuyen cao nh u chiem khoang t 900 en 2700 xuat phat t
la cach tr lieu chac chan nhat e ieu tr cng nhanh ong mach giap di, ay cung la mot dau
can giap cho ca hai nhom co va khong co trieu hieu ien hnh cua adenoma tuyen can giap.37
chng. Trong khi hnh anh cung mach mau nay khong lam
tang o nhay cua viec phat hien ban au cac
HNH ANH SIEU AM adenoma can giap th no cho phep phan biet vi
hach lympho, co kieu phan bo mach mau ron hach
Hnh dang trung tam.37-39
Nhng adenoma tuyen can giap thng co dang
hnh bau duc (Hnh 22-2). Giong nh cac tuyen can Kch thc
giap phnh to, chung co the c khao sat tren mat a so cac adenoma tuyen can giap dai 0,8 en 1,5
cat doc vung co co dang thon dai ien hnh. Neu cm va nang 500 en 1000 mg. Adenoma nho nhat
phat trien qua mc, chung se trai dai hn va co co the ch la tuyen phnh to nhe khong phat hien
dang hnh ong, tham ch hnh hai cc. Thng c bang mat thng luc mo nhng tren giai phau
chung phnh to khong can xng, hoac cc tren hoac benh co hien tng tang sinh te bao. Adenoma ln
cc di nh cu hanh tao nen cac dang nh tam nhat co the dai en 5 cm hay hn va nang tren 10
giac, bup mang hay hnh giot le.16,30-32 gam. Nong o canxi huyet thanh trc mo thng
cang cao neu u tuyen cang ln (Hnh 22-3).25-32
Tnh phan am
Adenoma tuyen can giap ien hnh thng co phan Benh tuyen a o
am giam do tuyen tang sinh te bao ong dang va Benh tuyen a o co the do tang san hay adenoma
co vai dai phan cach manh sinh am ben trong. Tnh a o. Ca biet, cac tuyen ph ai co dang sieu am
chat sinh am cua a so adenoma can giap ve can giong ve ai the vi cac adenoma tuyen can giap
ban giam hn mo giap (xem Hnh 22-2). Ngi ta khac (Hnh 22-6).16 Tuy nhien, cac tuyen ph ai co
Tuyen can giap 735
Hnh 22-3. Pho sinh am va cau truc ben trong cua adenoma can giap. A, phan am
day va phan am kem hon hp. Cat doc adenoma cho thay phan am day phan au va phan am
kem phan uoi. B, phan am khong ong nhat. Cat doc cho thay adenoma khong ong nhat lan
toa. C, cat doc cho thay adenoma 3 cm co phan nang trung tam. D, cat doc cho thay adenoma
4cm chu yeu la nang.
Hnh 22-4. Phan bo mach mau ien hnh cua adenoma. A, Doppler mau tren mat cat
doc cho thay adenoma can giap co tang dong mau so vi tuyen giap bnh thng. B, cat doc,
hnh Doppler mau nang lng cho thay s tang ti mau cua adenoma so vi tuyen giap.
the khong can xng, khong theo qui luat nao ca va to tren 2 cm, ngc vi adenoma ch khoang 1 cm.
do o, chan oan benh tuyen a o thng kho khan Cac carcinoma thng co b a cung, cau truc
tren sieu am. Hnh anh cua no co the nham lan vi khong ong dang va co cac nang ben trong, tuy
benh tuyen n oc hay bo sot chan oan neu nhien, cac u tuyen ln cung cho hnh anh tng
tuyen ph ai tiem an. t.40 Trong cac khao sat tien cu, co the phan biet
cac carcinoma vi adenoma lanh tnh ln. Mot dau
Carcinoma hieu sieu am ang tin cay trc mo khac e chan
Tren sieu am, cac carcinoma thng to hn u oan ac tnh nhng hiem gap, o la s xam lan vao
tuyen. Kch thc trung bnh cac carcinoma thng cac cau truc lan can nh c hay mach mau.
Hnh 22-5. Pho kch thc cua cac adenoma tuyen can giap. A, cat doc, adenoma tuyen can giap
to nhe 150mg, 0,6 x 0,2 cm. B, Adenoma kch thc trung bnh ien hnh 800 mg, 3 x 0,8 cm. C, Adenoma to
2500 mg, 4 x 2 cm.
giap. Adenoma cua tuyen can giap tren trong

trng hp ien hnh thng nam sat ngay mat sau
phan gia tuyen giap (Hnh 22-7). V tr ien hnh
cua cac adenoma tuyen can giap di a dang hn,
nhng thng nam ngay chop uoi cc di tuyen
giap (Hnh 22-8). Phan ln cac adenoma tuyen can
giap di nay nam sat pha sau tuyen giap, cac
trng hp con lai nam trong phan mem di
tuyen giap 1 cm en 2 cm. Sau khi khao sat mot
Hnh 22-6. Phnh to tuyen can giap a o. Cat doc qua
ben, ben oi dien cung khao sat tng t (Hnh 22-
vung co phai cho thay phnh to tuyen can giap tren va di
(mui ten). T, tuyen giap. 9). Tuy nhien co 1% en 3% cac adenoma tuyen
can giap lac cho, khong thay v tr ien hnh canh
tuyen giap. Bon v tr lac cho thng thay nhat
V TR U TUYEN c noi phan rieng sau ay.
Cach kham sieu am Cac v tr lac cho

Sieu am vung co e tm cac adenoma can giap Adenoma sau kh quan. V tr lac cho thng
c thc hien t the nam nga. Benh nhan nga gap nhat cua cac adenoma tuyen can giap tren la
co toi a ra sau nh em goi at di gia hai vai nam sau trong co, pha sau hay sau-ben kh quan
va ngi lam sieu am thng ngoi pha au benh (Hnh 22-10). Cac adenoma tuyen can giap tren co
nhan. Trong hau het cac trng hp, s dung au khuynh hng phat trien trong mo mem hng ve
do thi gian thc tan so cao (7.5 10 MHz) e at trung that sau. Bong lng do kh trong kh quan gay
c o phan giai khong gian va o ro net tot nhat. kho khan cho viec anh gia vung nay. Thng cac
benh nhan beo ph, phan mem co day hoac co adenoma ch nho nhe mot phan vao pha sau kh
bu giap a nhan to, nen s dung au do 5 MHz quan va phan con lai co the nhn thay c. Xoay
e co u o xuyen thau theo chieu sau can thiet. au benh nhan sang ben oi dien se tap trung va
anh gia c tot hn vao phan nho sau kh quan.
Cac v tr ien hnh au do nen co goc m trung bnh e khao sat c
Cach kham sieu am toan bo vung co e tm u v phan mem sau kh quan. Cach thc nay c lap
tr cac adenoma tuyen can giap co the xem giong lai cho viec khao sat phan co oi dien e nhan
nh cach phau thuat vien phau tch va nhan nh nh phan sau kh quan oi ben. Cach kham nay
ton thng mot cach t m khi phau thuat vung co. c xem giong nh thu thuat cua phau thuat vien
Khao sat bat au tng ben mot cua vung tuyen luon au ngon tay vao sau kh quan e s tm cac
Tuyen can giap 737
Hnh 22-7. Adenoma tuyen can giap tren. A, Cat doc va, B, cat ngang cho thay adenoma 2 cm
(mui ten) nam canh mat sau phan gia thuy phai tuyen giap, T. Tr, kh quan; CCA, ong mach canh
chung; JV, tnh mach canh trong; E, thc quan.
Hnh 22-8. Adenoma tuyen can giap di. A, Cat doc va, B, cat ngang cho thay adenoma 1
cm (mui ten) nam di chop uoi cc di thuy trai tuyen giap. Tr, kh quan; CCA, ong mach canh
chung; JV, tnh mach canh trong; E, thc quan.
Hnh 22-9. Pho v tr cua cac adenoma ien hnh cua tuyen can giap. A, Adenoma tuyen can
giap tren. Cat doc cho thay u tuyen nam sau phan gia tuyen giap. B, Adenoma tuyen can giap di. Cat
doc cho thay u tuyen 1 cm nam di cc di tuyen giap. C, Tang san. Cat doc cho thay cac tuyen can
giap tren va di phnh to.
Hnh 22-10. Adenoma lac chotrong khe kh quan-thc quan. A, Cat doc ben cho thay
adenoma tuyen can giap tren lac cho 2 cm (mui ten) nam sau trong phan thap cua co / trung that tren
canh cot song co (au mui ten) vi bong lng pha sau. B, Chup CLT qua phan thap cua co / trung that
tren cho thay adenoma lac cho (mui ten) ben trai khe kh quan-thc quan ke can vi thc quan, e.
Hnh 22-11. Adenoma lac chotrong trung that trc-tren. A, Cat ngang qua goc di
xng on cho thay adenoma tuyen can giap di hnh bau duc 1 cm (mui ten) trong mo mem trung
that trc-tren. B, Chup XQCLT qua trung that tren cho thay adenoma lac cho (mui ten) trong trung
that trc-tren sau trong can xng c canh cac mach mau ln.
adenoma sau kh quan. Adenoma trong trung that. V tr thng thay

Xoay toi a au benh nhan cung thng lam nhat cua cac adenoma tuyen can giap di lac cho
cho thc quan di chuyen sang pha oi dien cua kh la nam thap trong co hay trong trung that trc-tren
quan va thc quan b ep lai gia kh quan va cot (Hnh 22-11).42 Cac adenoma tuyen can giap
song co. Neu ta thay thc quan di chuyen chui thng c thay co dang cau truc phan am kem
hoan toan qua ben oi dien khi xoay au toi a th nam rieng biet vi tuyen c va mo xung quanh. e
o chnh la khoang sau kh quan c lua qua khao sat tot nhat vung nay, co benh nhan phai
mot ben co hieu qua va do o, no ay c bat ky nga toi a. Vi ky thuat nay va at au do co goc
adenoma can giap nao sau kh quan. m ra vung sau va hng xuong di.
Tuyen can giap 739
Hnh 22-12. Adenoma lac chotrong trung that trc-tren. A, Cat ngang qua
goc di xng on cho thay adenoma tuyen can giap di hnh bau duc 1 cm (mui ten)
trong mo mem trung that trc-tren. B, Chup CLT qua trung that tren cho thay adenoma
lac cho (mui ten) trong trung that trc-tren sau trong can xng c canh cac mach mau
ln.
tai cac au xng on, trng nhn sieu am co the chung co phan am giam, tng phan ro vi o
khao sat pha di en mc cac tnh mach vo danh. phan am cua nhu mo giap bao quanh. Cau truc ben
Neu cac adenoma nam thap hn mc nay hay xa trong va bieu hien cua chung giong nh cac
hn ve pha trc, ngay sau xng c th khong the adenoma ni khac cua co. Ve mat sieu am, u
nhn thay tren sieu am c. tuyen trong mo giap co bieu hien giong nh mot
Khi mot adenoma tuyen can giap tren lac cho nhan giap va do o, sinh thiet qua da la can thiet
trong trung that thng no nam vung sau-tren. e phan biet chung. Vai adenoma tuyen can giap
Nhng adenoma nay thng nam trong mat phang tren va di co the nam di bao gia hoac vo bao
sau hn so vi cac adenoma tuyen can giap di bao phu tuyen giap hay ben trong khe cua tuyen
va nam sau trong phan thap cua co hay trung that giap, nhng adenoma loai nay thng khong c
tren, do o, can s dung au do 5 MHz e co o xem la adenoma trong tuyen giap that s. No co
xuyen thau toi a. Nhng adenoma nay co le co the kho nhan nh c trong khi mo tr khi m
lien quan mat thiet vi dang nam sau kh quan va bao nay ra.8,34 Khi sieu am, cac adenoma nay co
nghiem phap xoay au c mo ta phan u tuyen bieu hien giong nh cac adenoma tuyen can giap
sau kh quan co the c ap dung tot ay. Vi t khac, chung nam ngay canh tuyen giap.
the co nga ra sau toi a va au do co goc m Adenoma khong xuong/trong bao canh. La
hng xuong di, trung that sau thnh thoang thay loai adenoma lac cho hiem gap. No co the nam
c en mc nh cua quai ong mach chu. Cac cao trong vung co tren hay vung ben co, gan cho
adenoma nam thap hn mc nay co the khong thay chia oi ong mach canh ngang mc xng mong
c tren sieu am. hoac dnh trong bao canh doc theo ng i cua
Adenoma trong tuyen giap. Loai nay t khi ong mach canh chung (Hnh 22-13).46-48 Ve mat
gap va co the xay ra adenoma can giap tren hoac phoi thai, cac adenoma nay co kha nang xuat phat
di.4,43-45 Hau het cac adenoma trong tuyen giap t cac tuyen can giap di nhng khong i xuong
nam ban phan sau cua phan gia en cc di hoac ch xuong mot phan va i ben trong hoac
tuyen giap, c mo tuyen giap bao quanh hoan canh bao canh bao quanh ong mach canh, tnh
toan va truc ln nhat cua chung la chieu tren-di mach canh va than kinh lang thang. Loai nay
(Hnh 22-12). Cac adenoma trong tuyen giap co khi thng hay b bo sot khi mo tr khi phau thuat vien
b bo sot khi mo v chung mem nh mo giap xung chu y ac biet, phai m bao canh va phau tch ben
quanh khi s nan. Cat tuyen giap hay cat thuy ban trong no.6,7,49 Khi sieu am, cac khoi nay co dang
phan co le la u e tm mot adenoma trong tuyen giong nh hach co ph ai nhe trong chuoi canh va
giap. Tuy nhien ve phng dien sieu am, adenoma sinh thiet qua da thng can thiet e khang nh s
tuyen can giap thng hien len thay ro v hien dien cua chung.
Hnh 22-13. Adenoma lac chotrong bao canh. A, Cat doc vung co phai cho thay adenoma can giap lac cho 2
cm (mui ten) pha sau tnh mach canh trong, JV. B, Xa hnh vi technetium-99m sestamibi cho thay o tang hoat tnh khu
tru trong co ben phai. Thuy phai tuyen giap a c cat bo trong lan mo that bai trc o, co khu tru mot adenoma can
giap lac cho ben phai. T, tuyen giap; SG, tuyen nc bot. (Theo Hopkins CR, Reading CC. Thyroid and parathyroid
imaging. Sem US CT MRI 1995;6:279-295.)
CNG CAN GIAP TON TAI HOAC TAI Cac phng tien chan oan hnh anh trc khi
PHAT mo lai la can thiet, va hau het cac chien lc ieu
tr eu khuyen cao s dung rong rai cac phng
Cng can giap ton tai la con tnh trang tang calxi tien khao sat trong tnh huong nay.16,59,60 a so cac
mau sau khi phau thuat cat bo can giap trc ay phau thuat vien thch thc hien trc khi mo lai
b sot. ieu nay thng do cac adenoma tuyen can nhng ky thuat n gian nhat, co o nhay nhat va
giap lac cho khong thay c khi mo, hoac do ky thuat t at tien nhat, do o, sieu am la ky thuat
benh ph ai tuyen can giap nhieu ni khong nhan hnh anh c chon la au tien. Sieu am chng to
biet c va do o, phau thuat cat bo cac mo tang la mot trong nhng phng thc co o nhay cao
chc nang b bo sot khi mo. Tang canxi mau ton nhat e phat hien adenoma trong tnh huong mo
tai sau mo c bao cao co t le t 3% en 10% lai.59 Hnh anh sieu am co the c bo sung, neu
nhieu nghien cu.50 Cng can giap tai phat c can, bang chup xa hnh hay cong hng t, khi cac
nh ngha la tnh trang tang canxi mau tr lai sau dau hieu sieu am gay phan van hay co nguy c
mot khoang thi gian 6 thang co canxi mau bnh cao.60,61 Cach tiep can nay cho thay a lam thay
thng, o la do s phat trien cua mot hay nhieu oi phng phap mo lai khong can hnh anh, co t
tuyen can giap tang chc nang t nhng tuyen bnh le thanh cong ch 60%, nho hn mot cach co y
thng trc o.51 Cng can giap tai phat thng ngha so vi ky thuat khong at tien nhng co t le
gap nhng benh nhan MEN I khong nhan biet thanh cong gan 90%.59
c trc. Mot nhom nho benh nhan b cng can giap
nhng benh nhan mo lai, ty le phau thuat tai phat xuat hien sau phau thuat ghep can giap t
thanh cong ch khoang 10% en 30% thap hn than trc ay do cat toan bo tuyen can giap trc
nhieu so vi lan mo au. Bi v seo va x hoa o, thng co bien chng suy than man tnh.62,63
vung co do lan mo au, t le b bien chng ha canxi Trong phau thuat nay, mot tuyen can giap c cat
mau tram trong sau mo va ton thng day than ra thanh nhieu manh nho roi nh vao ben trong c
kinh quat ngc thanh quan cao hn gap 20 lan.52-58 vung cang tay hoac c c-on-chum. Tren 20%
Khi khao sat sieu am nhng benh nhan a c en 33% benh nhan c ghep tuyen can giap t
mo lai, can quan tam ac biet en hau het cac v than se xuat hien tnh trang tang canxi mau phu
tr c xem la co can giap lac cho, e xem co thuoc manh ghep.63,64 Khi khao sat bang sieu am,
tuyen nao khong c phat hien ra lan mo au nhng manh ghep t than nay rat nho va rat giong
tien. vi cau truc am hoc cua mo c xung quanh.
Tuyen can giap 741
ADENOMA TUYEN CAN GIAP: NHNG

NGUYEN NHAN GAY DNG TNH GIA
Mach mau noi phnh len

Thc quan
C dai co
Nhan tuyen giap
Hach lympho co
rieng, cac tuyen phnh to nay co hnh anh sieu am

giong nh cac adenoma tuyen can giap khac (Hnh
22-6). Tuy nhien, cac tuyen nay phnh to khong oi
xng. Chan oan hnh anh thng khong can thiet
mac du sieu am c xem nh mot cong cu hnh
Hnh 22-14. Cng can giap xuat phat t mo can anh e anh gia o tram trong cua cng can giap
giap ghep t than. Cat doc mat trc cang tay trai cho th phat, c tnh bang so lng cac tuyen ph
thay hainot phan am kem 1 cm (mui ten) do s tang sinh mo
ai.70 Nhng benh nhan co ph ai tuyen can giap
can giap ghep t than.
tren sieu am, thng co nhng trieu chng lam
Nhng oi khi co the nhan dien c chung. Trong sang, cac ch so labo va cac dau hieu X quang cua
cng can giap tai phat phu thuoc manh ghep, mo cng can giap th phat nang hn nhng benh
ghep t than co hnh anh giong cac adenoma co, nhan khong co dau phnh to tuyen can giap. Co the
co dang phan am kem, b sac net, hnh bau duc, o dung sieu am e ho tr viec nh v tuyen can giap
c khoang 5 mm en 11 mm (Hnh 22-14).64,65 phnh to trc khi tien hanh phau thuat cat bo v
Khi viec nh v trc mo thanh cong, cac manh cng can giap th phat.71
ghep t than c tm thay de dang khi phau thuat
vien gay te tai cho va phan mo ghep c cat bo NHNG ANH GIA TRONG LY GIAI HNH
e tr chng tang canxi mau. ANH
CNG CAN GIAP TH PHAT Trng hp dng tnh gia

Cac cau truc bnh thng vung co nh nhng tnh
Cng can giap th phat ien hnh c tm thay mach nho nam canh tuyen giap, thc quan, va cac
benh nhan suy than man tnh. Ho khong co kha c dai co, co the giong nh cac u tuyen tuyen can
nang tong hp dang hoat ong cua vitamin D va do giap, gay ra tnh trang dng tnh gia trong khi
o, co tnh trang giam canxi mau man tnh, gay ra kham sieu am vung co (xem khung tren).
hien tng tang sinh tuyen can giap. Neu khong Vai tnh mach nho nam ngay mat sau ben cua
ieu tr, cng can giap th phat co the gay ra hien hai thuy tuyen giap, khi no co dang xoan hay dan
tng mat chat khoang cua xng, ong voi trong tng oan se giong nh adenoma nho cua can giap.
mo mem va nhanh chong voi hoa thanh mach. Cac ky thuat quet hnh giup xac nh cau truc o la
ieu tr cng can giap th phat bang phau thuat tnh mach ch khong phai la adenoma la: (1) dung
thng t khi at ra v lieu phap tham phan, than hnh anh hien th tc th nhieu mat cat ngang, doc
nhan tao la u thanh cong; tuy nhien, nhng va cheo e thay c cau truc ong cua tnh mach;
benh nhan co trieu chng nhng khang tr vi lieu (2) lam nghiem phap Valsalva co the co hien tng
phap noi khoa va tham phan mau, phau thuat cat mau thoang qua cua tnh mach; va (3) hnh anh
tuyen can giap ban phan hay cat toan phan kem pho hay dong Dopller mau chng to co dong chay
theo ghep lai bang t than c ch nh.60-69 ben trong tnh mach (Hnh 22-15).
Nhng benh nhan cng can giap th phat Thc quan chui mot phan vao mat sau-ben kh
thng co nhieu tuyen phnh to cung mot luc. Noi quan va giong nh mot adenoma to cua tuyen can
Hnh 22-15. Tnh mach nam canh tuyen giap giong vi adenoma tuyen can giap. A, Cat doc
cho thay mot cau truc phan am kem hnh bau duc 1cm (mui ten) nam canh mat sau tuyen giap, nghi ng la
adenoma tuyen can giap. B, Doppler mau cho thay co dong mau i qua long cau truc nay, chng minh o la
mot tnh mach.
Hnh 22-16. Thc quan giong vi adenoma tuyen can giap. A, Cat ngang vung co trai cho thay
mot cau truc phan am kem hnh bau duc 1 cm (mui ten) nam pha sau tuyen giap, T. C, ong mach canh
chung. Cau truc nay co the la u tuyen. B, Cat doc ben trai cho thay cau truc nay hnh ong (mui ten) va cha
dch trong long, o la thc quan.
giap.72 Xoay au benh nhan sang ben oi dien se C dai co nam canh mat trc ben cua song
tap trung c vao phan nay. Nhn can than cau co. Tren mat cat ngang, no co dang mot khoi hnh
truc nay tren mat cat ngang se thay co hnh anh tam giac phan am kem giong nh mot u tuyen ln
ong tam ien hnh cua ruot, vi lp c phan am nam sau tuyen giap. Tuy nhien, khi quet tren mat
kem ngoai vi va lp phan am day trung tam cua cat doc se thay chung co hnh dai va mong va co
dch trong long hay niem mac. Dung mat cat doc nhng ng van sinh am ien hnh cua c bam
se cho thay hnh dang ong cua cau truc nay (Hnh xng. Quan sat khi benh nhan nuot se rat hu ch,
22-16). Hnh anh hien th tc th khi benh nhan v khi nuot, tuyen giap va cac cau truc lan can nh
nuot se thay mot dong phan am sang cua dch adenoma can giap se di chuyen con c dai co do
nhay va bot kh trong long, chng to cau truc nay dnh vao cot song nen van nam yen. Cuoi cung, so
la thc quan. sanh vi ben co oi dien se thay co hnh anh oi
Tuyen can giap 743
Hnh 22-17. Nhan tuyen giap giong vi adenoma

tuyen can giap. A, Cat ngang qua co thay co nhan tuyen
giap khong ong nhat 1,5 cm (mui ten en) nam mat sau thuy
trai tuyen giap, T. ay co the la adenoma tuyen can giap. So
sanh vi khoi adenoma tuyen can giap thc s co phan am
kem, ong nhat 1 cm (mui ten trang) nam trong mo mem pha
sau thuy phai tuyen giap. (theo Hopkins CR, Reading CC.
Thyroid and parathyroid imaging. Sem US CT MRI 1995;6:279-
295.)
xng tng t v c dai co la cau truc oi nam ca

hai ben cot song co. ADENOMA TUYEN CAN GIAP: CAC NGUYEN
Nhng cau truc benh ly co kha nang gay dng NHAN GAY AM TNH GIA
tnh gia la bu nhan tuyen giap va hach co.32,73
Cac nhan tuyen giap co the thay hn 40% benh Adenoma phnh t
nhan c sieu am vung co v benh ly tuyen can Phnh giap a hat
giap.74 Neu nhan giap nam mat sau, no co the U tuyen cua tuyen can giap lac cho
giong nh mot khoi adenoma tuyen can giap. Mot
dau hieu co the hu ch trong trng hp nay la
ng sinh am mong phan cach adenoma tuyen can
giap (phat xuat t ben ngoai tuyen giap) vi tuyen
giap. Cac nhan giap phat xuat t ben trong tuyen va cho ket qua dng tnh gia tren sieu am va chup
giap nen khong thay c mat phang mo phan xa hnh a c mo ta.77
cach.75 Ve mat hnh thai, cac nhan giap khong giong
vi adenoma can giap cho no thng co mot phan Trng hp am tnh gia
la nang va mot so co voi hoa. Cac nhan giap cung Co ba tnh huong ln trong khi kham cho ket qua am
thng co phan am hon hp, khong ong nhat, trong tnh gia la u tuyen to t, cac adenoma dch chuyen ve
khi adenoma can giap th phan am kem va ong nhat pha sau va b che khuat bi mot phnh giap to ro ret,
(Hnh 22-17). Khi khong the phan biet c va cac adenoma lac cho ( xem bang tren).
adenoma can giap vi nhan giap bang cac tieu chuan Cac adenoma to t la nham lan thng gap nhat
hnh anh th co le sinh thiet qua da la can thiet. v cac khoi nay qua nho, kho phan biet chung vi
Hach co ph ai co dang bau duc, phan am kem tuyen giap va mo mem xung quanh. Cac phnh giap
giong u tuyen tuyen can giap, nhng no cung thng a hat gay tr ngai cho viec phat hien cac adenoma
co mot dai manh sinh am trung tam hay ron hach tuyen can giap bang hai cach. Th nhat, tuyen giap
bao gom m, mach mau va mo si, o la hnh anh phnh to se lam dch chuyen cac cau truc nam pha
e phan biet hach vi adenoma can giap.76 Tren sieu sau tuyen giap ra xa au do hn. Do o, can dung
am, cac hach co thng thay vung co ben, trong au do 5 MHz thay cho au 7,5 MHz e co c o
chuoi canh trong nam canh ben tnh mach canh xa xuyen thau can thiet, tuy nhien, no cung lam giam
tuyen giap. Tuy nhien, thnh thoang, cac adenoma o phan giai khong gian. Th hai, cac bu phnh
can giap co the thay vung co ben trong bao canh, giap a nhan co ng b a cung va cau truc am
ac biet nhng benh nhan co tien can mo lai. Sinh khong eu an, gay can tr cho viec phat hien mot
thiet qua da la can thiet e phan biet adenoma tuyen can giap ke ben ph ai. Mot vai adenoma lac
tuyen can giap vi cac hach co bat thng. Co t cho nam sau kh quan hay sau trong trung that se
nhat hai trng hp hach co ph ai co cha cac u khong the tiep can, khong the thay c do bong
hat sarcoid (sarcoid granulomas) gay tang canxi mau lng cua kh nam pha tren va cua xng.
TNH CHNH XAC phng tien chan oan hnh anh trc mo a cai
Sieu am thien tnh chnh xac tren tong the neu so sanh vi ch
o nhay cua viec nh v cac adenoma tuyen can dung mot phng tien chan oan hnh anh.82 Khi s
giap bang sieu am trong benh cng can giap dung nhieu phng tien e khao sat, hau het cac
nguyen phat thay oi tuy ni, nhng hau het cac bao trung tam, th sieu am la mot chon la tot au tien
cao trong khoang t 70% en 80%.32,60,75,78-86 o ac cua ky thuat hnh anh trc mo v tnh chat khong
hieu co le c cai thien vi choc hut bang kim nho xam nhap, re tien, tnh chnh xac va o nhay co tnh
(FNA). Nh se mo ta chi tiet phan sau ( xem canh tranh cua no.
chng Sinh thiet qua da), FNA la mot tr thu ac
lc cho kham nghiem sieu am. Trong trng hp Ban luan: Dung chan oan hnh anh hay
nghi ng mot khoi adenoma, hut nhng mau benh khong dung chan oan hnh anh trong
pham gi i phan tch te bao khong khac g th benh cng can giap nguyen phat
nghiem PTH.60, 78-90 Cac ch nh cua chan oan hnh anh trc mo cac
Trong cng can giap tai phat hay ton tai, o tuyen can giap benh nhan cng can giap nguyen
nhay cua sieu am trong viec nh v cac adenoma a phat thay oi tuy ni. nhng trung tam y khoa co
c bao cao trong khoang 36% en 63%60,61,91-95 phau thuat vien nhieu kinh nghiem, chan oan hnh
Sieu am c tang cng them FNA cung nh th anh tuyen can giap thng qui trc mo thng
nghiem PTH, o ac hieu gan nh 100%.95 ieu khong c thc hien.116 ieu nay la do hien tng
quan trong nen hieu la trong hau het cac khao sat canxi mau tr ve bnh thng sau mo tren 95% en
lam sang ln, 70% en 80% cac adenoma tuyen can 98% va do t le mac bien chng hiem xay ra sau mo
giap thay c vung co hay tiep can c qua cat bo can giap, neu phau thuat vien co kinh nghiem
vung co benh nhan mo lai v cng can giap.54,56,57 thc hien.59,117,118 Ngoai ra, nhng benh canh kho
Do o, mot kham xet sieu am vung co can than, t m chan oan hoac benh nhan co nguy c cao, khong
la quan trong oi vi nhng benh nhan mo lai nay. chac la phng phap chan oan hnh anh trc mo
Neu sieu am khong thay adenoma th cac v tr lac trong cng can giap nguyen phat c s dung co
cho trong trung that nen c xem xet.60,95,96 hieu qua th u lam cai thien t le thanh cong cao
cho cuoc mo.116,11
Cac phng tien chan oan hnh anh khac Tuy nhien, cung co nhieu e ngh s dung
Cac phng tien khac thng dung nh v adenoma phng tien chan oan hnh anh trc mo trong
tuyen can giap la chup cong hng t MRI97-100 xa cng can giap nguyen phat. Cac kham nghiem hnh
hnh vi technetium-99m sestamibi.101-107 Cac phng anh trc mo vach ra cach tiep can nhanh va bao ton
tien t c dung ngay nay la chup cat lp ien toan hn khi tham do moi ben co e co c s c lng
(CT), chup quang mach va lay mau tnh mach.108-113 ung khi phau tch vung co hai ben.96 Vi cach tham
Nhng nghien cu ban au anh gia ca hai phng kham nh v, nhng li iem co le la lam giam co y
phap sieu am nga thc quan114 va chup cat lp phat ngha thi gian mo cung nh giam so ngay nam vien,
positron115 chng to co thanh cong vai benh nhan. nguy c bien chng va ton thng mo.50,96 Mac du co
Nhng benh nhan ang xem xet mo lai, chup xa hnh the co mot t le cao tnh trang tang canxi mau ton tai
sestamibi hoac MRI la can thiet khi sieu am am tnh, khi cat bo can giap mot ben, neu co hnh anh trc
ac biet la anh gia vung sau kh quan va phan trong mo nham lan mot adenoma th phat oi ben, cac
trung that ma sieu am khong khao sat c. Chup adenoma oi hay ba co tan xuat di 5%, co vai
mach va lay mau tnh mach la nhng cach thc xam nghien cu neu len nhng tan xuat di 1%16,96 Neu
nhap hn, at tien hn va oi hoi ky thuat cao hn adenoma au tien c tm thay bang phng tien
cac phng tien hnh anh ke tren. Nhng cach nay chan oan hnh anh th khong chac se co nhieu c
con co mot nguy c cao kho chap nhan c cac may thay c nhng khoi u th phat oi ben.
bien chng va a giam dan cac trung tam. Nhng Nhng e ngh dung chan oan hnh anh trc mo
khao sat anh gia o nhay cua s phoi hp nhieu trong cng can giap nguyen phat cung ghi nhan
Tuyen can giap 745
rang co vai u tuyen nam thap trong trung that c SIEU AM TRONG KHI MO
tm thay va cach tiep can bang phau thuat co the
thay oi hoac lac quan hn neu hnh anh cho thay Sieu am trong khi mo oi khi ho tr ac lc cho viec
khoi u nam gan tuyen c.50 tm kiem cac adenoma tuyen can giap khi mo, ac
nh v chnh xac trc mo ac biet giup giam biet trong boi canh mo lai.124,125 Co the s dung au
thieu t le mac bien chng benh nhan co nguy c do thong thng co tan so cao (7,5 en 10MHz) c
cao, nh nhng benh nhan co benh tim, phoi tram bao bang bao plastic vo trung hay dung au do trong
trong.119-122 Sieu am con co the giup rut ngan thi mo vo trung chuyen dung. Sieu am trong mo la
gian anh gia can thiet trc khi mo cap cu benh phng phap tot nhat e nh v nhng tuyen can
nhan len cn tang canxi mau e doa tnh mang tram giap bat thng nam pha sau hay trong nhu mo
trong.122 Cuoi cung, khi chan oan sinh hoa tang tuyen giap. Nhng bat thng cac tuyen tren kho
canxi mau khong ro rang th chan oan hnh anh mot tm hn.125 Neu sieu am trong mo phat hien c
adenoma giup chan oan xac nh tnh trang cng mot tuyen can giap bat thung th thi gian mo co
can giap. the rut ngan lai. Tuy nhien trong hau het cac khao
Trong trng hp cng can giap tai phat hay sat, sieu am trong mo khong co anh hng en ket
ton tai, ro rang la co ch nh khao sat nh v, v t le qua cuoc mo.
thanh cong cua phau thuat thap hn va t le mac bien
chng cao hn khi phai mo lai.16 Nhng khao sat SINH THIET QUA DA
nh v trc mo trong trng hp cng can giap tai
phat, eu anh hng en ca hai phng dien thanh Sinh thiet qua da di hng dan cua sieu am c
cong va thi gian cho cuoc mo lai. Trong mot nghien dung lam tang tan suat chan oan xac nh trc mo
cu 157 benh nhan phai kham nghiem lai v cng trong trng hp nghi ng co bat thng tuyen can
can giap tai phat hay ton tai, t le ieu tr phau thuat giap, ac biet nhng benh nhan la ng vien phai
la 89%, va chng minh rang nhng khao sat nh v mo lai.87-90,126-128 Ky thuat nay lam tang o ac hieu
tien cu co gop phan cho t le thanh cong cao nay.94 cua sieu am, v no cho phep phan biet chnh xac u
Cung vay, khi khoi adenoma c nh v trc mo tuyen tuyen can giap vi nhng ton thng benh ly
th se giam c thi gian cuoc mo. khac, nh nhan giap hay hach co. Them na, no con
V a so cac adenoma tuyen can giap tai phat tac ong tot en phau thuat vien, mot ket qua sinh
hay ton tai xay ra vung co hay trung that tren qua thiet dng tnh bao am cho mot cuoc mo lai ngoai
mot ng mo co hiem hn ng m xng c106 y muon.
cho nen kham sieu am vung co la bien phap c Neu adenoma tuyen can giap nghi ng co v tr
chon la au tien e nh v trong benh canh cng nam xa tuyen giap, th chan oan phan biet chu yeu
can giap tai phat hay ton tai.93,123 vi hach co. Sinh thiet qua da bang kim khau knh
Hnh 22-18. Sinh thiet kim qua da adenoma tuyen can

giap. Cat doc cho thay adenoma tuyen can giap 1,5 cm hnh
bau duc (mui ten thang) nam sau trong mo mem co benh
nhan cng can giap tai phat. Kim (mui ten cong) sinh thiet
cha ben trong nhng te bao can giap, xac nhan khoi nay la
adenoma tuyen can giap. T, tuyen giap.
nho khong cat mo, nh kim chch 25-gauge tieu c va mau co the pha loang vi 1 ml nc muoi
chuan, u e hut te bao, chng to la te bao can giap sinh ly va em phan tch PTH bang phng phap
hay te bao hach lympho (Hnh 22-18).129 Neu nghi mien dch huynh quang.60,87,88,90,131,132. Nong o cao
ng adenoma tuyen can giap nam canh tuyen giap, PTH la bang chng khong the choi cai cua mo can
can phai lay mau mo ln hn (mau mo hiem hn giap. Khong co bien chng nao c ghi nhan khi
mau te bao) e phan biet mo tuyen giap va mo can lam sinh thiet kim qua da trong trng hp nghi ng
giap.130 Mau mo co the lay c bang kim nho (21- adenoma tuyen can giap.
en 25-gauge) loai cat c. Nhng kim cat c o chnh xac cua sinh thiet qua da trong chan
oi khi kho a qua cac lp mo mem, nong va dai oan phan biet gia tuyen can giap va cau truc khac
vung co. Tuy nhien, mot kim nh vay se de dang at la 87%, trong loat khao sat 52 benh nhan.127 Nhng
qua mot kim khac to hn, ngan hn loai khong cat, sai sot khi sinh thiet la do lay khong u mo tuyen
co vai tro lam nong a qua cac lp mo nong. can giap.
Hn na, khi phan tch mo hay te bao, dch hut ra
Hnh 22-19. Huy adenoma tuyen can giap bang con.

A, Sieu am mau cat ngang qua mot adenoma tuyen can giap
1,5 cm (mui ten thang) co vong mach mau bao quanh nam thap
trong vung co phai cua benh nhan co adenoma tuyen can giap
tai phat nhng khong the phau thuat c v suy tim nang.
Nhieu mach mau ben trong va bao quanh u tuyen. CCA ong
mach canh chung; JV, tnh mach canh trong. B, di sieu am,
ethanol c tiem vao nhieu cho trong khoi u tuyen, lam cho
mo quanh au kim co phan am day sang thoang qua (mui ten
cong). C, Mot ngay sau huy u bang ethanol, sieu am mau cat
ngang qua co ben phai cho thay khoi u va mo xung quanh co
giam dong mau en. Dong mau giam ro ret, neu so sanh vi
hnh anh trc khi tiem ethanol. (Theo Reading CC.
Ultrasound-guided percutaneous ethanol ablation of solid and
cystic masses of the liver, kidney, thyroid, and parathyroid.
Ultrasound Q 1994;12:67-68.)
Tuyen can giap 747
HUY KHOI U BANG CON

THAM KHAO
Sieu am c s dung e hng dan tiem ethanol Phoi hoc va giai phau
1. Gilmour JR. The gross anatomy of the parathyroid glands. J Pathol
qua da vao cac tuyen can giap phnh to bat thng 1938:46:133-148.
trong lieu phap huy khoi u bang hoa chat.133-140 Hien 2. Weller GL Jr. Development of the thyroid, parathyroid and thymns
nay, huy khoi u bang ethanol khong c s dung glands in man. Carnegie Institution of Washington: Contributions to
Embryology 1933:24(141):93-139.
thng qui e ieu tr benh nhan cng can giap 3. Mansberger AR, Wei JP. Snrgical embryology and anatomy of the
nguyen phat, nhng no co vai tro la mot lieu phap thyroid and parathyroid glands. Surg Clin North Am 1993:73:727-746.
4. Akerstrom G, Malmaeus J, Bergstrom R. Surgical anatomy of human
thay the cho nhng benh nhan khong the phau thuat,
parathyroid glands. Surgery 1984:95:14-2'!.
nh nhng ngi khong chu mo hay nhng benh 5. Edis AJ. Surgical anatomy and technique of neck exploration for
nhan trong tnh trang cap cu v cn tang canxi primary hyperparathyroidism. Surg Clin North Am 1977: 57:495-504.
6. Thompson NW, Rckhauser FE, Harness JK. The anatomy of primary
mau ac tnh e doa tnh mang.141 Vai benh nhan hyperparathyroidism. Surgery 1982:92:814-821.
tham phan mau b adenoma can giap tai phat sau cat 7. Edis AJ, Purnell DC, van Heerden JA. The undescended "parathymus
ban phan can giap trc ay hoac khang tr vi thuoc An occasional cause of failed neck exploration for hyperpara-
thyroidism. Ann Surg 1979:190:64-68.
calcitriol, cung nh hiem hn, nhng benh nhan 8. Wang C-A. The anatomic basis of parathyroid surgery. Ann Surg 1976:
ghep can giap t than b cng can giap tai phat, co 183:271-275.
9. Norris EH. The parathyroid glands and the lateral thyroid in man: their
le la nhng ng vien cua lieu phap nay.136,142-145
morphogenesis, histogenesis, topographic anatomy and prenatal
Huy khoi u bang con c thc hien vi te tai growth. Carnegie Institution of Washington: Contributions to
cho sau khi sinh thiet qua da xac nh co mo can Embryology 1937:26(159):247-294.
10. Castleman B, Roth SI. Tumors of the parathyroid glands. In: Atlas of
giap hoac co tang PTH trong mo. a kim nho (22- Tumor Pathology. Fascicle 14, 2nd series. Washington, DC: Armed
25-gauge) en nhieu vung trong khoi u va tiem Forces Institute of Pathology: 1978.
ethanol 96% vi the tch gan bang na the tch khoi 11. Russell CF. Grant CS, van HeerdenJA. Hyperfunctioning supernume-
rary parathyroid glands: an occasional cause of hyperparathyroidism.
u. Quan sat di sieu am hien th tc th se thay mo Mayo Clin Proc 1982:57:121-124.
bu tr nen sinh am manh ong thi vi thuoc tiem 12. Hopkins CR, Reading CC. Thyroid and parathyroid imaging. Sem US
vao. Tnh chat sinh am nay bien mat cham sau CT MRl 1995:16:279-295.
khoang thi gian khoang mot phut. Co hien tng Cng can giap nguyen phat
13. Heath H III, Hodgson SF. Ennedy MA. Primary hypepara-
giam ro ret s ti mau cua adenoma sau khi chch
thyroidism: incidence, morbidity, and potential economic impact in a
ethanol, co le do huyet khoi gay tac cac mach mau community. N Engl J Med 1980:302:189-193.
can giap (Hnh 22-19). Nhng lan tiem c lap lai 14. Van I leerden JA, Beahrs OH, Woollier LB. The pathology and sur-
gical management of primary hyperparathyroidisin. Surg Clin North
moi ngay hoac moi vai ngay cho en khi nong o Am 1977-,57-.557-563.
canxi mau tr ve bnh thng. Co nhieu trng hp 15. Wang CA. Surgery of the parathyroid glands. Adv Surg 1966:5:109-
can phai tiem ba en nam lan. 127.
16. Kaplan EL, Yashiro T, Saiti G. Primary hyperthyroidism in the 1990s.
Cac ket qua tiem ethanol nh la mot cach ieu Choice of surgical procedures for this disease. Ann Surg 1992:215:
tr cng can giap cho nhieu ha hen. Trong loat 300-317.
17. Black WC III, Utiey JR . The differential diagnosis of parathyroid
nghien cu 18 benh nhan cng can giap nguyen
adenoma and chief cell hyperplasia. Am J Clin Pathol 1968;49:761-
phat c ieu tr bang phng phap tiem ethanol, 775.
co 2/3 so ngi c ieu tr thay co cai thien ve 18. Prinz RA, Gamvros 01, Sellu D et al. Subtotal parathyroidectomy for
primary chief cell hyperplasia of the multiple endocrine neoplasia
mat sinh hoa hoac co tnh trang lam sang on nh type I syndrome. Ann Surg 1981 ;193:26-29.
trong 6 thang hay hn sau lieu phap nay.135 mot 19. Van Heerden JA, Kent RB 111, Sizemore GW et al. Primary hyper-
nghien cu khac vi 12 benh nhan136 cng can giap parathyroidism in patients with multiple endocrine neoplasia
syndromes . Arch Surg 1983:118:533-535.
th phat, co 7 trng hp co cai thien ve sinh hoa va 20. Weiland LH. Practical endocrine surgical pathology. In: van Heerden
lam sang. Cac tac dung phu cua phng phap huy u JA, ed. Common Problems in Endocrine Surgery. Chicago: Year
Book Medical Publishers; 1989.
bang ethanol trong hai loat nghien cu nay, tren tong
21. Schantz A, Castlernan B. Parathyroid carcinoma: a study of 70 cases.
so 30 benh nhan, gom co liet day thanh am thoang Cancer 1973:31:600-605.
qua 4 benh nhan va liet thanh am thng xuyen 22. Castleman B, Roth Sl. Tumors of the parathyroid glands. In: Atlas of
Tumor Pathology. Fascicle 14, 2nd series. Washington, DC: Armed
mot benh nhan. Forces Institute of Pathology: 1978.
23. Shane E , Bilezikian JP. Parathyroid carcinoma: a review of 62 primary hyperparathyroidism. World J Surg 1990;14:342-348.
patients. Endocrinol Rev 1982:3:218-226. 47. Doppman JL, Shawker TH, Krudy AG et al. Parathymic parathyroid:
24. Holmes EC, Morion DL, Ketcham AS. Parathyroid carcinoma: a computed tomography, ultrasound and angiographic findings.
collective review. Ann Surg 1969;169:631-640. Radiology 1985;157:419-423.
25. Purnell DC, Smith LH, Scholz DA et al. Primary hyperpara- 48 Doppman JL, Shawker TH, Fraker DL et al. Parathyroid adenoma
thyroidism: a prospective clinical study. Am J Med 1971;50:670-678. within the vagus nerve. AJR 1994;163:943-945.
26. Purnell DC, Scholz DA, Smith LH et al. Treatment of primary hyper- 49. Kurtay M, Crile G Jr. Aberrant parathyroid gland in relationship to
parathyroidism. Am J Med 1974;56:800-809. the thymus. Am J Surg 1969;! 17:705.
27. Clark OH, Duh QY. Primary hyperparathyroidism: a surgical Cng can giap keo dai hoac tai phat
perspective. Endocrinol Metab Clin North Am 1989;18:701-714. 50. Irvin GL, Prudhomme DL, Deriso GT et al. A new approach to para-
28. Kaplan RA, Snyder WH, Stewart A et al. Metabolic effects of parathyroidectomy. Ann Surg 1994;219:574-581.
thyroidectomy in asymptomatic primary hyperparalhyroidism. J Clin 51. Clark OH, Way LW, Hunt TK. Recurrent hyperparathyroidism. Ann
Endocrinol Metab 1976:42:415-426. Surg 1976;184:391-399.
29. Gaz RD, Wang CA. Management of asymptomatic hyperpara- 52. Levin KE, Clark OH. The reasons for failure in parathyroid
thyroidism. Am J Surg 1984;147:498-501. operations. Arch Surg 1989;124:911-914.
Hnh anh sieu am 53. Cheung PSY, Borgstrom A, Thompson NW. Strategy in reoperative
30. Graif M, Itzchak Y, Strauss S et al. Parathyroid sonography diagnostic surgery for hyperparathyroidism. Arch Surg1989;124:676-680.
accuracy related to shape, location and texture of the gland. Br 54. Palmer JA, Rosen IB. Re-operative surgery for hyperparathyroidism.
J Radiol 1987:60:439-443. Am J Surg 1982;144:406-410.
31. Randel SB, Gooding GAW, Glark OH et al. Parathyroid variants: 55. Prinz RA, Gamvros 01, Allison DJ et al. Re-operations for hyperpara-
ultrasound evaluation. Radiology 1987:165:191-194. thyroidism. Surg Gynecol Obstet 1981;152:760-764.
32. Reading CC, Charboneau JW, James LM et al. High-resolution 56. Grant CS, Charboneau JW, James EM et al. Re-operative parathyroid
parathyroid sonography. AJR 1982:139:539-546. surgery. Wien Klin Wochenschr 1988;100:360-363.
33. Obara T, Fujimoto Y, Ilo Y et al. Functioning parathyroid lipo- 57. Wells SA. Advances in the operative management of persistent
adenomareport of four cases: clinicopathological and ultrasono- hyperparathyroidism. Mayo Clin Proc 1991:66:1175-1177.
graphic features. Endocrinol Jpn 1989;36:135-145. 58. Brennan MF, Marx SJ, Doppman J et al. Results of re-operation for
34. Lack EF, dark MA, Buck DR et al. Cysts of the parathyroid gland: persistent and recurrent hyperparathyroidism. Ann Surg-198l;194:
report of two cases and review of the literature. Am Surg 1978: 44: 67l-676.
376-381. 59. Grant CS, van Heerden JA, Charboneau JW et al. Clinical mana-
35. Krudy AC, Doppman JL. Shawker TH et al. Hypertunctioning cystic gement of persistent and/or recurrent primary hyperparathyroidism.
parathyroid glands: computed tomography and sonographic findings. World J Surg 1986;10:555-565.
AJR 1984;142:175-178. 60. Rodriquez JM, Tezclman S, Siperstein AE et al. Localization proce-
36. Sistrom CL. Hanks JB, Feldman PS. Supraclavicular mass in a woman dures in patients with persistent or recurrent hyperparathyroidism.
with hyperparathvroidism. Invest Radiol 1994:2:244-247. Arch Surg 1994;129:870-875.
37. Wolf RJ, Cronan JJ. Monchik JM. Color Doppler sonography: an 61 Higgins CB. Role of magnetic resonance imaging in hyperpara-
adjunctive technique in assessment of parathyroid adenomas. J thyroidism. Radiol Clin North Am 1993;31:1017-1028.
Ultrasound Med 1994; 13:303-308. 62. Brunt LM, Sicard CA. Current status of parathyroid autotransplan-
38. Calliada P. Bergonzi M, Passamonti C et al. II contributo del color tation. Sem Surg Oncol 1990;6:115-121.
Doppler nello studio ecografico delle ghiandole paratiroidi iper- 63. Brunt LM, Wells SA Jr. Parathyroid transplantation: indications and
plasiche. Radiol Med (Torino) 1989:78(6):607-611. results. In: van Herrden JA, ed. Common Problems in Endocrine
39. Gooding GAW, Clark OH. Use of color Doppler imaging in the Surgery. Chicago: Year Book Medical Publishers; 1989.
distinction between thyroid and parathyroid lesions. Am J Surg 1992 64. Winkelbauer F, Ammann ME, Langle F et al. Diagnosis of hyperpara
164:51-56. thyroidism with US after autotransplantation: results of a prospective
40. Daly BD, Coffey SL. Behan M. Ultrasonographic appearances of study. Radiology 1993;186:255-257.
parathyroid carcinoma. Br J Radiol 1989:62:1017-1019. 65. Hergan K, Neyer U, Doringer W et al. MR imaging in graft-
41. Edmonson GR, Charboneau JW, James EM et al. Parathyroid dependent recurrent hyperparathyroidism after parathyroidectomy
carcinoma: high-frequency sonographic features. Radiology 1986; and autotransplantation. Mag Res Imag 1995;5:541-544.
161:65-67. Cng can giap th phat
V tr adenoma 66. Wilson RE, Hampers CL, Bernstein DS et al. Subtotal parathyroidec-
42. Clark OH. Mediastinal parathyroid tumors. Arch Surg 1988;123: 1096 tomy in chronic renal failure: a seven-year experience in a dialysis
- 1099. and transplant program. Ann Surg 1971:174:640-652.
43. Thompson NW. The techniques of initial parathyroid exploration and 67. Diethelm AC, Adams PL, Murad TM et al. Treatment of secondary
re-operative parathyroidectomy. In: Thompson NW, Vinik AI, eds. hyperparathyroidism in patients with chronic renal failure by total
Endocrine Surgery Update. New York: Grune & Stratton; 1983. parathyroidectomy and parathyroid autograft. Ann Surg 1981;193:
44. Al-Suhaili AR, Lynn J, Lavender JP. Intrathyroidal parathyroid 777-791.
adenoma: preoperative identification and localization by parathyroid 68. Reid DJ. Surgical treatment of secondary and tertiary hyperpara-
imaging. Clin Nucl Med 1988;13:512-514. thyroidism. Br J Clin Pract 1989;43:68-70.
45. Spiegel AM, Marx SJ, Doppman JL et al. Intrathyroidal parathyroid 69. Leapman SB, Filo RS, Thomalla JV et al. Secondary hyperpara-
adenoma or hyperplasia; an occasionally over- looked cause of thyroidism: the role of surgery. Ann Surg 1989:55:359-365.
surgical failure in primary hyperparathyroidism. JAMA 1975;234: 70. Gladziwa U, Ittel TH, Dakshinamurty KV et al. Secondary hyper-
1029-1033. parathyroidism and sonographic evaluation of parathyroid gland
46. Fraker DL, Doppman JL, Shawker TH et al. Undescended para- hyperplasia in dialysis patients. Clin Nephrol 1992: 38;162-166.
thyroid adenoma: an important etiology for failed operations for 71. Takebayashi S, Matsui K, Onohara Y et al. Sonography for early
Tuyen can giap 749
diagnosis of enlarged parathyroid glands in patients with secondary thyroid adenomas in patients who have undergone surgery. PI.
hyperparathyroidism. AJR 1987:148:911-914. Noninvasive imaging methods. Radiology 1987:162:133-137.
93. Reading (XL Gliarboneau J\V, James EM et al. Postoperative para-
Nhng bay trong ly giai
thyroid high-frequency sonography: evaluation of persistent or
72. Ngo C, Sarti DA. Simulation of the normal esophagus by a para-
recurrent hyperparathyroidism. AJR 1985:144:399-402.
thyroid adenoma. J Clin Ultrasound 1987;15:421-424.
94. Grant GS, van Heerden JA, Charboneau JW et al. Clinical
73. Karstrup S, Hegedus L. Concomitant thyroid disease in hyperpara-
management of persistent and for recurrent primary hyperpara-
thyroidism: reasons for unsatisfactory ultrasonographical localization
thyroidism. World J Surg 1986:10:555-565.
of parathyroid glands. Eur J Radiol 1986;6:149-152.
95. Kairaluoma MV, Kellosalo .1, Makarainen H et al. Parathyroid re-
74. Funari M, Campos Z, Gooding GAW et al. MRI and ultrasound
exploration in patients with primary hyperparathyroidism. Ann
detection of asymptomatic thyroid nodules in hyperparathyroidism. J
Chirurg Gyn 1994:83:202-206.
Comput Assist Tomogr 1992;16:615-619.
96. Pearl A.T, Ghapnik JS, Freeman JL et al. Pre-operalive localization
75. Scheible W, Deutsch AL, Leopold GR. Parathyroid adenoma:
of 25 consecutive parathyroid adenomas: a prospective imaging/
accuracy of preoperative localization by high-resolution realtime
surgical correlative study. J Otolaryngol 1993:22:301-306.
sonography. J Clin Ultrasound 1981;9:325-330.
76. Sutton RT, Reading CC, Charboneau JW et al. US-guided biopsy of Cac phng phap hnh anh hoc khac
neck masses in postoperative management of patients'with thyroid 97. Yao M, Jamieson G. Blend R. Magnetic resonance imaging in pre-
cancer. Radiology 1988;168:769-772. operative localization of diseased parathyroid glands: a comparison
77. Nabriski D, Bendahan J, Shapiro MS et al. Sarcoidosis masquerading with isotope scanning and ultrasonography. Can J Surg 1993:36:241-
as a parathyroid adenoma. Head Neck 1992;14:384-386. 244.
98. Slovens SK. Gliang J, Glark OH et al. Detection of abnormal para-
Tnh chnh xac
thyroid glands in postoperative patients with recurrent hyperpara-
78. Simcone JF, Mueller PR, Fcrrucci JT Jr et al. High-resolution real-
thyroidism: sensitivity of MR imaging. AJR 1993;160:607-612.
time sonography of the parathyroid. Radiology 1981:141:745-751.
99. Kang YS, Rosen K; Clark OH et al. Localization of abnormal para-
79. Kobayashi S, Miyakawa M, Kasuga Y et al. Parathyroid imaging
thyroid glands of the mediastinum with MR imaging. Radiology-
comparison of 201 Tl-99mTc subtraction scintigraphy, computed
1993;189:137-141.
tomography, and ultrasonography. Jpn J Surg-1987;17:9-13.
100. Wright AR, Goddard PR, Nicholson S et al. Fat-suppression
80. Buchwach KA, Mangum WB, Hahn FW Jr. Preoperative localization
magnetic resonance imaging in the preoperative localization of para-
of parathyroid adenomas. l.aryngoscope 1987;97:13-15.
thyroid adenomas. Clin Radiol 1992;46:324-328.
81. Attie JN, Khan A, Rumancik WM el al. Preoperative localization of
101. Lee VS, Wilkinson RH, Leight GS et al. Hyperparathyroidism in
parathyroid adenomas. Am J Surg 1988:156:323-326.
high-risk surgical patients: evaluation with double-phase technetium-
82. Erdman WA, Breslau NA, Weinreb JC et al. Noninvasive localization
99m sestamibi imaging. Radiology 1995;195: 624-633.
of parathyroid adenomas: a comparison of x-ray, computed
102. Billy HT, Rimkus DR, Hartzman S et al. Technetium-99m sesta-
tomography, ultrasound, scinligraphy and magnetic resonance
mibi single agent localization versus high-resolution ultrasono-
imaging. Mag Res Imag 1989:7:187-194.
graphy for the preoperative localization of parathyroid glands in
83. Summers GW, Dodge DL, Kammer H. Accuracy and cost-ef-
patients with hyperparathyroidism. Ann Surg 1995;61:882-888
fectiveness of preoperative isotope and ultrasound imaging in
103. Schurrer ME, Seabold JE, Gurll NJ et al. Sestamib i SPECT scinti-
primary hyperparathyroidism. Otolaryngol Head Neck Surg 1989;100:
graphy for detection of postoperative hyperfuuctioning parathyroid
210-217.
gland. AJR 1996;166:1471-1474.
84. Kohri K, Ishikawa Y, Kodama M et al. Comparison of imaging
104. Mazzeo S, Cararnella D, Lencioni R et al. Comparison among
methods for localization of parathyroid tumors. Am J Surg 1992;
sonography double-tracer subtraction scintigraphy, and double-phase
164:140-145.
syntigraphy in the detection of parathyroid lesions. AJR 1996;166:
85. Gooding GA. Sonography of the thyroid and parathyroid. Radiol Clin
1465-1470.
North Am 1993:31:967-989.
105. Burke GJ, Wei .IP, Binet EF. Paratliyroid scintigraphy with iodine-
86. Weinberger MS, Bobbins KT. Diagnostic localization studies for
123 and ''''"'Tc-seslamibi: imaging tindings. AJR 1993:161:1265-1268.
primary hyperparathyroidism: a suggested algorithm. Arch Oto-
106. Thompson GB, Mullan BP, Grant GS et al. Paratliyroid imaging with
laryngol Head Neck Surg 1994:120:1187-1189.
technetium-99m sestamibi: an initial institutional experience. Surgery
87. Bergenfelz A, Forsberg L, Hederslrom E et al. Preoperative
1994;116:966-973.
localization of enlarged parathyroid glands with ultrasonically guided
107. Oates E. Improved parathyroid scintigraphy with Tc-99m MIB1, a
fine needle aspiration for parathyroid hormone assay. Acta Radiol
superior radiolracer. Appl Radiol March 1994:37-40.
1991:32:403-405.
108. Sommer B, Welter Hr\ Spelsberg F el al. Computed tomography for
88. Sacks BA, Pallotta JA, Cole A et al. Diagnosis of parathyroid
localizing enlarged parathyroid glands in primary hyperpara-
adenomas: efficacy of measuring parathormone levels in needle
thyroidism ,J Comput Assist Tomogr 1982:6:521-526.
aspirates of cervical masses. AJR 1994:163:1223-1226.
109. Stark DD, Gooding GAW. Moss AA et al. Parathyroid imaging:
89. MacFarlane MP, Fraker DL, Shawker TH et al. Use of preoperative
comparison of high-resolution computed tomography and high-
fine-needle aspiration in patients undergoing re-operation for primary
resolution sonography. AJR 1983:141:633-638.
hyperparathyroidism. Surgery 1994;! 16:959-965.
110. Okerlund MD, Slieldon K. Corpuz S et al. A new method with high
90. Sardi A, Bolton JS, Mitchcll WT et al. Imnumoperoxidase confir-
sensitivity and specificity for localization of abnormal parathyroid
malion of (utrasonicallv guided fine needle aspirates in patients with
glands. Ann Surg 1984:200:381-387.
recurrent hyperparathyroidism. Surg Gynecol Obstet 1992; 175:563-
111. Ferlin G, Borsato N, Cameram M et al. New perspectives in lo-
568.
calizing enlarged parathyroids by technetiiim-thallium subtraction
91. Levin KF, Gooding GAW. Okerlund M et al. Localizing studies in
scan. J Nucl Med 1983:24:438-441.
patients with persistent or recurrent hyperparathyroidism. Surgery
112. Krudy AC, Doppman JL, Miller DL et al. Work in progress:
1988;102:917-924.
abnormal parathyroid glands: comparison of nonselective arterial
92. Miller DL, Doppman JL, Sliawker TH et al. Localization of para-
digital arteriography. Selective parathyroid angiography, and venous 130. Karstrup S, Glenthoj A, Hainau B et al. Ultrasound-guided histolo-
digital arteriography as methods of detection . Radiology 1983:148: gical, fine-needle biopsy from suspect parathyroid tumors: success-
23-29. rate and reliability of histological diagnosis. Br J Radiol 1989:62:981-
113. Krudv AC. Doppman JL. Miller DL et al. Detection of mediastinal 985.
parathyroid glands by nonselective digital arteriography. AJR 1984: 131. Doppman JL, Krudy AG, Marx SJ et al. Aspiration of enlarged
142: 693-695. parathyroid glands for parathyroid hormone assay. Radiology- 1983;
114. Henry J, Audiffret J, Denizol A et al. Endosonography in the 148:31-35.
localization of parathyroid tumors: a preliminary study. Surgery-1990: 132. Winkler B, Gooding GAW. Montgomery GK e t al. Immuno-
108:1021-1025. peroxidase confirmation of parathyroid origin of ultrasound-guided
115. Hellman P. Alustrom H, Bergslrom M et al. Positron emission fine needle aspirates of the parathyroid glands. Acta Cytologica
tomography with 11C-methionine in hyperparathyroidism. Surgery 1987:31:40-44.
1994; 116:974 - 981. Huy u bang con
Ban luan: khao sat hnh anh hay khong trong cng can 133. Gharboneau JW, Hay ID, van Heerdeu JA. Persistent primary
giap hyperparathyroidism: successful ultrasound-guided percutaneous
116. W'ei JP- Burke GJ, Mansberger AR Preoperalive imaging of ethanol ablation of an occult adenoma. Mayo Clin Proc 1988:63:913-
abnormal parathyroid glands in patients with hyperparathyroid disease 917.
using combination Tc-99m-pertechnelale and Tc-99m-sestamibi 134. Karstrup S, Holm HH, Glenthoj A et al. Nonsurgical treatment of
radionuclide scans. Ann Surg 1994:219:568-573. primary hyperparathyroidism with sonographically guided per-
117. Roe SM, Burns RP, Graham LD et al. Cost-effectiveness of pre- cutaneous injection of ethanol: results in a selected series of patients.
operative localization studies in primary hypcrparathyroid disease. AJR 1990;154:1087-1090.
Ann Surg 1994:219:582-586. 135. Karstrup S, Transbol I, Holm HH et al. Ultrasound-guided chemical
118. Shaha AR, La Rosa CA, Jaffe BM. Parathyroid localization prior to parathyroidectomy in patients with primary hyperparathyroidism: a
primary exploration. Am J Surg 1993:166:289-293. prospective study. BRJ Radiol 1989:62:1037-1042.
119. Wu DTD, Shaw JHF. The use of pre-operative scan prior to neck 136. Solbiati L, Giangrande A, DePra L. et al. Percutaneous ethanol
exploration for primary hyperparathyroidism. Aust, NZJ Surg-1988; injection of parathyroid tumors under ultrasound guidance: treatment
58: 35-38. for secondary hyperparathyroidism. Radiology 1985:155:607-610.
120. Brewer WH, Walsh JW, Newsome HH Jr. Impact of sonography on 137. Verges BL, Gercueil JP, Jacob D et al. Results of ultrasonically
surgery for primary hyperparathyroidism. Am J Surg l983-145:270- guided percutaneous ethanol injection into parathyroid adenomas in
272. primary hyperparathyroidism. Actn Endocrinol 1993;129:381-387.
121. Russell GFJ, Laird JD, Ferguson WR. Scan-directed unilateral 138. Karstrup S, Hegedus L ., Holm HH. Acute change in parathyroid
cervical exploration for parathyroid adenoma: a legitimate approach? function in primary hyperparathyroidism following ultrasonically
World J Surg 1990;14:406-409. guided ethanol injection into solitary parathyroid adenomas. ACTA
122. Windeck R, Olbricht TH, Littmann K ct al. Halessonographie in der Endocrinol 1993;129:377-380.
hypercalamischen Krise. Dtsch Med Wochenschr 1985;110:368-370. 139. Karstrup S. Ultrasonically guided localization, tissue verification,
123. Wang CA. Parathyroid re-exploration: a clinical and pathological and percutaneous treatment of parathyroid tumors. Danish Med Bull
study of 112 cases. Ann Surg 1977;186:140-145. 1995;42:175-191.
140. Reading GG. Ultrasound-guided percutaneous ethanol ablation of
Sieu am trong khi mo
solid and cystic masses of the liver, kidney, thyroid and parathyroid.
124. Kern KA, Shawker TH, Doppman JL et al. The use of high-
Ultrasound Q 1994:12:67-68.
resolution ultrasound to locate parathyroid tumors during re-
141. Karstrup S, Lohela P, Apaja-Sarkkinen Vl et al. Non-operative
operations for primary hyperparathyroidism. World J Surg 1987; 11:
hypercalcemic crisis. Actn Med Scnnd 1988:224:187-188.
579-585.
142. Takeda S. Michigishi T, Takazakiira E. Ultrasonically guided per-
125. Norton JA, Shawker Tl 1, Jones BL et al. Intraoperative ultrasound
cutaneous ethanol injection to parathyroid autografts for recurrent
and reoperalive parathyroid surgery: an initial evaluation. World Surg
hyperparathyroidisni. Nephron 1993:65:651-652.
1986:10:631-638.
143. Takeda S, Michigishi T. Takaxakura L. Successful ultrasonically
Sinh thiet qua da guided percutaneous ethanol injection for secondary hyperpara-
126. Gooding CAW, Clark OH , Stark DD et al. Parathyroid aspiration thyroidism. Nephron 1992:62:100-103.
biopsy under ultrasound guidance in the postoperative hyperpara- 144. Kitaoka M, Fukagawa M. Ogata K et al. Reduction of functioning
thyroid patient. Radiology- 1985:155:193-196. parathyroid cell mass bv ellianol injection in chronic dialysis patients.
127. Solbiati L, Montali G, Groce F et al. Parathyroid tumors detected by Kydney Int 1994:46:1110-1117.
fine-needle aspiration biopsy under ultrasonic guidance. Radiology 145. Giangrande A, Gastiglioni A, Solbiali L et al. Ultrasound-guided
1983; 148:793-797. ' percutaneous fine-needle elliaiiol injection into parathyroid glands in
128. Charboneau JW, Grant GS, James EM et al. High-resolution ultra- secondary livperparatlivroidism. Nephrol Dial Transplant 1992:7:412-
sound-guided percutaneous needle biopsy and intraoperative ultra- 421.
sonography of a cervical parathyroid adenoma in a patient with 146. Gintin G, Karstrup S, Uadefoged S et al. Tertiary hyperpara-
persistent hyperparatlivroidism. Mayo Clin Proc 1983:58:497-500. thyroidism treated by ullrasonically guided percutaneous fine-needle
129. Clenthoj A, Karstrup S. Parathyroid identification by ultrasonically ethanol injection. Nephron 1994:68:217-220.
guided aspiration cytology. Is correct cytological identification
possible? APMIS 1989:97:497-502.
C H N G 2 3
Tuyen nhu

Ellen B. Mendelson, M.D.
D A N B A I
CH NH SIEUAM U diep the (Phyllodes tumor)

TRANG THIET B U x tuyen khong lo
KY THUAT SIEU AM VU X hoa khu tru (Local fibrosis)
THU THAP D LIEU Hamartoma
GIAI PHAU SIEU AM TUYEN VU U m (Lipoma)
PHNG CACH ANH GIA KHOI U Nang ba nhn (Sebaceous Cyst)
NANG TUYEN VU U nhu (Papilloma)
CAC KHOI U AC VA HON HP Nang sa (Galactocele)
ac iem sieu am va cac mc o nghi ng O ap xe
Khoi u ac tnh Seo hnh nan hoa (Radial scar)
Carcinoma ong tuyen CAC THU THUAT SIEU AM CAN THIEP
Carcinoma tieu thuy tham nhiem Ch nh va cac nguyen tac c ban
Carcinoma dang tuy Chuan b benh nhan , dung cu va ky thuat
Carcinoma dang nhay Ky thuat choc kim qua da
Carcinoma tieu quan Cac ky thuat ac biet
Carcinoma dang nhu CHAN THNG VU VA CAC THAY OI CAU
Khoi u lanh tnh TRUC SAU PHAU THUAT.
U x tuyen (Fibroadenoma)
Hien nay chup nhu anh qui c ang la phng tr cho viec nhan nh cac hnh thai benh ly giup
phap chan oan hnh anh quan trong nhat oi vi ly giai. Ngoai tr sieu am, con lai hau het cac
benh ly tuyen vu. Cac phng phap chan oan phng phap tren eu c ap dung mot cach han
khac bao gom sieu am, Doppler pho va Doppler che. Trong hai thap nien va qua, sieu am a gi
mau, cong hng t (MRI), cat lp ien toan (CT), c mot v tr quan trong trong chan oan va x
hnh anh hoc hat nhan vi cac chat nh 99mTc tr cac benh ly tuyen vu.
sestamibi oi vi ung th va 99mTc sufur dang keo Co hai mc o khac nhau trong qua trnh tiep
e anh dau cac hach va chup nhu anh ky thuat can e anh gia tnh trang tuyen vu :
so.1 Chan oan da vao ien toan (computer-aided Tam soat carcinoma tuyen vu
diagnosis = CAD) hien ang c phat trien e ho Chan oan va ieu tr cac benh lanh tnh va
ac tnh cua tuyen vu .

Muc ch duy nhat cua viec tam soat la tm CH NH CUA SIEU AM VU
carcinom tuyen vu: phat hien e ha thap t le t
vong.2-4 Hieu qua cua chng trnh tam soat tuy Xac nh ac iem cua khoi s thay hay nhn thay
thuoc vao o nhay va o chnh xac cua khao sat tren nhu anh la dang nang hay ac
anh gia khoi s thay ngi tre tuoi (< 30 tuoi)
vi phng phap de ap dung rong rai, chap nhan
hoac mang thai va cho con bu
c, mang lai li ch cao va nguy c thap. Xac nh ap xe ngi b viem tuyen vu
Sieu am vu khong phu hp cho viec tam soat anh gia cac cau truc bat thng khong s thay
ung th vu, cac ket qua nghien cu xa va nay va chan oan nhu anh khong chac chan
bang cac thiet b bang tay hoac t ong eu cho y Giup chan oan loai tr mot khoi u nghi ng la
kien nh tren.5,6 Voi hoa li ti la mot dau hieu quan nguyen nhan cua mot vung mat o khong oi
trong cua ung th vu giai oan sm c nhu anh xng tren nhu anh .
phat hien ra trong hn 50% trng hp ung th vu Khang nh hoac quan sat ro hn ton thng c
ma lam sang khong s thay c, trong khi o sieu nhn thay khong hoan toan hay ch the hien tren
am lai phat hien ra mot cach khong thng xuyen.7 mot chieu the cua nhu anh ( nh gan thanh ngc )
Hng dan cac thu thuat can thiep nh choc hut
Trong vai tro tam soat u, sieu am vu rat phu thuoc
nang , sinh thiet bang kim loi ln , sinh thiet choc
vao ngi thc hien va vao ky thuat, ton thi gian hut bang kim nho, dan lu ap xe , nh v trc
va v vay se ton kem hn.5 ieu quan trong nhat mo va chup ong sa.
la ket qua cua cac nghien cu tien cu ve s hu
hieu sieu am phan giai cao trong viec phat hien
cac ung th vu an, khong s thay tren lam sang .
Cac trieu chng vu nh au va s thay khoi sieu am can thiep mot cach thch hp. e quyet
thng la bieu hien cua cac thay oi bnh thng nh se sieu am hay lam thu thuat choc do di s
tuyen vu theo chu ky kinh va cac benh ly lanh tnh hng dan cua sieu am, chuyen gia hnh anh can
nh nang, benh hach va dien tien viem. Cac trieu phai xem xet kha nang cua hai phng phap tren
chng nay thng do nhng thay oi sinh ly, gay lo co cung co cho chan oan cua nhu anh hay thay
lang nhieu cho ngi phu n khi bc vao la tuoi oi hng x tr khong.8,9
co t le b ung th vu cao. Luc nay sieu am tuyen
vu ong gop nhieu nhat vao chan oan va x tr CH NH SIEU AM
cac roi loan vu. Sieu am lam tang o ac hieu
cua nhu anh va co vai tro vo gia trong viec xac Cac ch nh tren c dung cho ca benh nhan hau
nh tnh chat nang hay ac cua cac khoi u. phau va vu nam gii (xem khung). Hien tai,
Khi s dung ket hp vi nhu anh va kham lam ngi ta khuyen cao khong dung sieu am tam soat
sang, sieu am tr nen khong the thieu cho viec tong the vu day e tm u nghi ng v co mot t le
chan oan va x tr cac benh ly lanh va ac tnh. sai sot nhng benh nhan nay.5
Ngoai viec xac nh cac nang, tien bo ve may
moc, au do phan giai cao, cai tien ky thuat a
nang cao viec anh gia cac khoi u ac va a ra CAC TRANG THIET B
c cac mc o nghi ng khac nhau cho cac khoi
u. Ngoai ra, s de chu cho benh nhan cung kha Sieu am vu a c s dung t nam 1951 bi Wild
nang quan sat ng i cua kim lam cho sieu am va Reid thay c u co kch thc 2 en 3 mm
tr thanh mot ky thuat ngay cang c a chuong bang dau do mode A 15 MHz.8 Cac nghien cu
trong viec hng dan cac thu thuat can thiep. mode B dan dan s dung au do co tan so thap
e thuan li cho viec khao sat hnh anh tuyen hn. Hai loai thiet b c dung trong sieu am vu:
vu can co phng tien hien ai, nhan vien can co loai t ong va loai cam tay.
thi gian va nang lc e tong hp cac dau hieu Noi lo s phong xa ion hoa khi chup nhu anh
tren nhu anh va tren sieu am e hoan tat chan se gay ung th tao ra nhu cau tm cac phng phap
oan nhanh va hieu qua. Khao sat nhu anh can khac thay the e tam soat ung th vu va cac may
c theo doi va ho tr bang sieu am hay thu thuat sieu am vu t ong ap ng c yeu cau nay.10
Tuyen nhu 753
Hnh 23-1. Viem tuyen vu va ap xe. A, Phu n 43 tuoi b au va sot, nhu anh the chech
trong-ngoai cho thay mo mat o cao. Phu nhe va cac vung khong eu cua chu mo (mui ten) phan
tren cua vu. B, Sieu am cho thay vung sang tang phan am (E) chng to phu do viem nam ben trong
mot khoi tu ap xe khu tru hnh ch C (mui ten) c dan lu di hng dan cua sieu am.
Ca hai loai nam sap va nam nga eu c phat cac au do tan so cao nay la 3 cm hoac t hn, toi
trien, vi au do co tan so gia 4,0 va 7,5 MHz.11 u hoa o phan giai cua khoi u nong. Neu au do
Li iem cua may sieu am vu t ong bao gom khong c hoi tu ung khoang gia khoi u,
viec hien th nhieu ton thng mot cach ang tin phan am anh gia co the xay ra oi vi nang (Hnh
cay hn giup cho viec so sanh vi cac ket qua cu 23-2). Ngay ca vi au do tan so cao, viec s dung
de dang hn va nhat la t phu thuoc vao ngi lam cac tui em bu am cung se cai thien o phan giai
sieu am. cua ton thng trong vung gan nam di da va rat
Viec s dung cac thiet b sieu am vu t ong nong.12,13 Chang bao lau na, au do tan so cao
gan nh a b huy bo v khong c coi la mot ky hn se sm c cac nha san xuat gii thieu e
thuat tam soat ay u. Nam 1989, Basset bao cao sieu am vu. Sieu am Doppler mau va Doppler pho
53% trong 319 chuyen gia hnh anh a s dung cung a c s dung trong chan oan benh ly
sieu am vu trong thc hanh. Trong so nay, 93% s tuyen vu mac du gia tr cua chung trong viec phan
dung au do cam tay va ch 7% s dung cac may biet khoi u ac lanh va ac tnh van cha c xac
quet t ong at tien, cong kenh va lam viec nang nh.14-18 Cac nghien cu ang tren ng khang
nhoc nay.12 T o viec s dung sieu am vu ngay nh gia tr cua chat tng phan tiem tnh mach nh
cang tang len va moi khao sat hnh anh tuyen vu albumin vi the trong viec lam tang o nhay va o
toan dien nen s dung sieu am . ac hieu cua sieu am mau va Doppler nang lng
Cac au do cam tay thch hp hn cho viec nham phat hien khoi u va phan loai khoi u lanh
xem xet ac iem khoi u, viec khao sat c thc tnh hoac ac tnh.19
hien nhanh hn may t ong. au do cam tay cung
hng dan cho thu thuat de dang hn. Cac au do KY THUAT SIEU AM VU
nay a dang ve ac tnh, thiet ke va chat lng.
Co u cac loai au do vi tan so t 7 en 10 MHz, Sieu am tao c hoi cho tham kham lam sang va
ieu chnh iem hoi tu ong, dang phased-array, sieu am tuyen vu va nen co san nhu anh e oi
linear-array, annular array. Cac au do kch thc chieu vi cac dau hieu sieu am. Sieu am vung
chuan hoac nho hn dung trong khi mo eu thch ngoai bien cua vu c thc hien de dang t the
hp cho sieu am vu mac du cac au do kch thc nam nga hi nghieng ben. Vai cua ngi benh va
chuan co ve hieu qua hn so vi cac au do dung than tren ben vu khao sat can c nang len
cho muc ch sieu am tong quat. Vung hoi tu cua me ngoai e giam bt o day cua mot phan t tren
Hnh 23-2. Nang n gian: tam quan trong cua viec chnh vung hoi tu. A, Vi
vung hoi tu at nong sat pha trc, xay ra anh gia a am phan hoi trong trng gan. B, Chuyen
dch vung hoi tu xuong di, at phan trc ton thng vao gia, xac nh c tnh chat phan
am trong cua nang.
ngoai mo vu. Canh tay cung ben a len tren vi chech nay, hau het mo vu o ve ben oi dien. Coi
khuyu gap va ban tay at thoai mai di co. Canh nh o xuyen thau cua song am ay u khi thay
tay ben kia van at canh than. Trong t the nga- c cac c ngc ben di va cac xng sn.
Tuyen nhu 755
e xem cac vung khac ngoai vung phan t am t the ng nh luc chup nhu anh, cac tng
tren ngoai, nen e t the nam nga, vi tay xep quan giai phau se c gi nguyen.
ben than hay at di au. Neu muc ch tham Neu van khong chac chan khi oi chieu dau
kham la anh gia bat thng a s thay hoac neu hieu s c va thay tren nhu anh vi bat thng
ton thng ch cam nhan c khi benh nhan ngoi tren sieu am, at mot marker can quang tren da
hoac ng, nen e benh nhan t the o va benh pha tren ton thng nh anh gia ban au. Sau o
nhan lay ngon tay ch vao vung bat thng. Cac khao sat lai vung nay vi t the ng (Hnh 23-3).
mat cat nen hng trc tiep vao vung nghi van. Thay marker tai vung nghi ng chng to a khao
Cach sieu am quet theo ban knh dang nan hoa sat cung mot ton thng. Neu van con nghi ng, co
va quet vuong goc vi hng tren t ngoai bien the cam mot kim vao ton thng va sau o chup lai
vao trung tam la cac cach c e ngh v theo nhu anh. Mot cach khac e xac nh s tng ong
ung cau truc c the hoc phan nhanh ong tuyen va la choc hut, neu la nang, ton thng bien mat tren
sap xep cac thuy trong tuyen vu hnh non.13 e mo nhu anh. Tiem mot t khong kh vao bat thng ac
ta het toan bo tuyen vu, ky thuat quet nay hau nh va lap lai nhu anh co the khang nh cac u la mot.
la nhan thc trc giac. Mot cach tong quat, cac Cac thu thuat tren thng khong can thiet mac du
phan t va cac vung c quet theo cac mat cat chung co ch.
doc va ngang. Vung bat thng nghi ng c ieu quan trong la sieu am vu khong nen ha
khao sat theo kieu trc giao (vi hai ng cat xuong thanh lumpography tc ch khao sat vung
vuong goc nhau) sao cho co the nhan ra cac gia u sng. Can phai lu y ti cac cau truc giai phau nen
ma khong lam la ton thng that. V du, mot tieu xung quanh ton thng va co the phai lap lai tham
thuy m hien len giong nh khoi u x tuyen hnh kham e tai xac nh cac vung lien quan qua o
bau duc tren mot mat cat nhng khi xoay au do sau cua ton thng va hnh thai cua cac tieu thuy
900, tieu thuy m hien len thon dai hn la tron. m xung quanh, day chang Cooper va cac giao
Hnh anh cua phc hp num va quang vu oi dien si tuyen (fibroglandular interfaces)
hoi thao tac ac biet.20,21 Num vu tao nen s thay
oi ot ngot b tren da va lam kem thay ro mo THU THAP D LIEU
vung sau. Bong lng sau do khong kh chen gia
be mat da khong eu va au do. Cac thanh phan Cac dau hieu sieu am co the c lu gi trong
si trong num vu cung co the tao bong lng che phim, bang video, he thong ghi ky thuat so hay cac
khuat vung sau quang vu. Khao sat mo di num cong cu lu gi khac.22 Cung giong nh nhu anh,
vu bang cach at au do ke can num vu va chech ghi chu hnh anh cung phai phu hp. Mac du khong
vao vung sau quang vu. Neu cac bat thng nghi co phng phap nao c chap nhan tren toan cau,
ng nam trong da hoac nong trong mo di da, at hnh anh can co ten benh nhan, so ho s, ngay
mot mieng em bu am hoac mot tui ay dch tren sinh, vu ben nao, v tr vung benh ly theo v tr kim
da se cai thien c o phan giai cua cac cau truc ong ho, s o hay cac he thong de hieu kha va v
nam trong vung gan. tr cua au do ( cat doc hay ngang ). Cung can mo
Viec anh gia a ton thng bang sieu am co ta ton thng nam v tr nh:
the b nham lan v co the nhan ton thng len 1. sau quang vu
nhieu lan do quan sat t cac goc o va v tr khac 2. mot phan ba trc
nhau. Mot cach e em cac khoi u la co gang phan 3. phan gia cua vu
biet chung bang tay, ay no ra khoi trng khao 4. mot phan ba sau
sat. Sau o xem chu mo xung quanh tm u hay 5. vung nach hay vung vu pha nach
nang kem theo. e o ton thng chnh xac can tm va o
T the benh nhan luc chup nhu anh khac vi t ng knh ln nhat va coi nh truc doc. ng
the luc lam sieu am va anh hng ti cau truc giai knh vuong goc vi la truc ngang, ng knh th
phau. Khi ngi phu n nam nga, vu be ra, ba o tren mat cat vuong goc. Neu ang theo doi
khoang cach gia da va thanh ngc giam i so vi khoi u lanh tnh nh fibroadenoma hoac ang anh
luc chup nhu anh t the ng. e giup tao c gia ap ng hoa tr lieu cua mot carcinoma, o ba
moi tng ong nhu anh-sieu am, neu cung sieu chieu cua khoi cho phep tnh ra the tch khoi u.
Hnh 23-3. Xac nh s tng ong nhu anh-sieu am. Mot khi tm thay bat thng khi quet
the nam nga hoac nam nga-chech, co the yeu cau benh nhan ngoi thang day trong khi van gi
nguyen au do tren vu. B, at mot marker can quang tai v tr tren va thc hien chup nhu anh e
khang nh tnh tng ong cua cac dau hieu sieu am va nhu anh.
Tuyen nhu 757
Cach ghi chu ung an va thong nhat se giup cac mo x tuyen hoac u. Nhn chung, mo x tuyen
lan sieu am sau de dang hn va de trao oi hn vi (fibroglandular tissue) co phan am tang trong khi
cac ong nghiep lam sang. a so u thng co phan am kem hay phan am
trong. Mo tuyen ong nhat tang am lan toa gap
GIAI PHAU SIEU AM TUYEN VU moi la tuoi ac biet ngi rat tre thng tng
ng vi vu mat o cao tren nhu anh, v vay viec
Thanh phan giai phau tuyen vu va cac cau truc tm ra khoi u tren nhu anh tr nen rat kho khan .
xung quanh ( da, ong tuyen, mo m, chu mo, num Day chang Cooper la phan nang mo lien
vu, mach mau, c sau tuyen vu va xng sn ) co ket cho tuyen vu. Tren sieu am, chung hien len
cac ac iem rieng tren sieu am. Phc hp da di dang nhng ng cung mong, tang am. ac
hien len di dang hai ng tang am manh cach biet phan di cua vu, cac day chang Cooper cat
nhau bi mot dai giam phan am, chan b (Hnh 23- ngang mo si tuyen co the tao ra bong lng sau
4).23 Da bnh thng day en 0,2 cm nhng co the ang lu y. Thay oi goc cua au do so vi vu hay
day hn pha di gan nep di vu. thay oi lc ep len tuyen vu co the lam mat bong
Cac tieu thuy m co dang bau duc tren mot lng t o co the quan sat het mo tuyen vu.
mat cat va thon dai ra mat cat vuong goc. Chung Cac n v tieu thuy ong tuyen tan (terminal
co phan am kem tng oi so vi mo tuyen xung duct lobular units = TDLU) la cac n v giai phau
quanh24 va co the co o tang phan am trung tam cua quan trong ma t o phat sinh nhieu benh ly lanh
mo lien ket. Cac tieu thuy m di da va trong tnh (nang, benh hach-adenosis, fibroadenoma) va
tuyen vu thng ln hn cac tieu thuy m vung ac tnh.25 TDLU co the ph ai hoac thoai trien,
trc c ngc. phan anh tuoi va cac khac biet sinh ly va tang sinh
Chu mo tuyen vu hien len ong nhat, tang khi mang thai, chang han, chuan b cho s tiet sa.
phan am so vi cac tieu thuy m nhng co the co TDLU tang san la nhng vung giam phan am co
cac vung giam phan am ben trong do mo m. the nhan ra c tren sieu am;26 mot TDLU nho,
Khong thng xuyen, chu mo tuyen thng c bnh thng co the khong nhan dien c v la mot
xen vao bi cac ong tuyen nho phan am kem. Chu cau truc giai phau tiem an ngay ca vi sieu am vu
mo tuyen vu bnh thng tren nhu anh bien oi a phan giai cao. o phan giai khong gian cua au do
dang co the anh gia lai bang sieu am. Cac vung ngay ca vi tan so ti 12 MHz, co the han che viec
mat o khong oi xng tren nhu anh co the la do quan sat cac n v quan trong nay.
Cac ong dan sa xep dang nan hoa quanh
num vu tng ng vi 7 en 20 phan thuy tuyen
the hien khau knh ln dan khi hoi tu tai num vu.
Cac ong nay hien len nh nhng cau truc dang ong
vi khau knh t 1 en 8 mm (Hnh 23-5).27 Cac
ong nay tr nen nho hn va phan nhanh phan
ngoai vi tuyen vu.
Num vu co o phan am trung bnh va lam
giam song am, gay ra bong lng sau. Thc hien
mat cat chech sau num vu hoac s dung tui em bu
am cho phep nhn thay vung sau num vu (Hnh 23-
6). oi khi num vu bnh thng hien len di dang
mot cau truc giam phan am, hnh bau duc, gii han
Hnh 23-4. Da bnh thng. Hnh sieu am vi au do 7,5 ro trong giong nh mot adenoma nam nong neu
MHz va mot em tren mat da (P) cho thay hai ng tang
phan am (mui ten) vi mot lp mong giam phan am nam
dung ng cat xeo.
gia. Bnh thng da day 0,2 mm hoac t hn ngoai tr nep Mo nhu c bao trong mot bao can bao gom
di vu. Thay cac tieu thuy m di da (F) map mo giam lp nong va lp sau.27 Nhng lp can nay nhan ra
phan am. Lp tang am pha sau m la chu mo si tuyen (G). di dang nhng ng mong du thng khong
cac cau truc phan nhanh phan am kem ben trong mo tuyen la
nhn thay. Lp can nong oi khi thay c di
cac ong dan sa va G chong len ni phan nhanh. Vung tang
am hi cong trong m di da la day chang Cooper. chan b, con lp sau nam ben tren lp m sau vu.
Hnh 23-5. Cac ong dan sa. A, Hai ong nhanh ln bnh thng tu lai nhau khi en gan
num vu. Phan sau cua hai ong hi cong (mui ten). Trong mo tuyen co nhieu ong nho hn (au
mui ten). Tieu thuy m, FL. B, Ong dan sa gian dang chuoi hat tao thanh nhng bong dang
nang kem nhng not trong thanh (mui ten) bieu hien cua u nhu trong ong dan sa.
Hai lp nay tach nhau bi cac day chang Cooper. Xng sn hnh bau duc, giam phan am la nhng
Mot khi thay c c ngc bao am song am cau truc cach quang nam pha sau c ngc (Hnh
xuyen thau u tai vung chu mo tuyen vu tai o. 23-7). Chung giam thau song am va tao bong lng.
Tuyen nhu 759
MO TA SIEU AM CAC KHOI VU
V tr
So lng
Kch thc
Hnh dang
Tron
Bau duc
Khong eu
ng b
Trn lang
a cung nho
a cung ln
Hnh 23-6. Phc hp num-quang vu. Dung tam em
Khong eu hoac dang gai
bu am (P) va be goc au do vao vung sau quang vu, co the
Gii han khong ro
thay mo sau num vu. Tr khi nghieng au do neu khong tiep
Hng
xuc kem vi num vu se tao nen bong lng che khuat vung
Thanh phan ben trong
sau quang vu. Da sau quang vu gan num se day hn (mui ten
ac
am) va ngoai vi mong hn. Nhng cau truc dang ong, en,
Nang
nho bieu hien cac ong dan sa (mui ten manh). R ch xng
Hon hp .
sn, M la c ngc
o phan am
Phan am trong
Phan am giam
Phan am tang
Tnh ong nhat
ong nhat
Khong ong nhat
Giao dien vi chu mo
Dang thang mong
Vien tang phan am
Khong eu
o truyen am pha sau
Hnh 23-7. Cac xng sn. Hnh cat doc cho thay Tang am
xng sn hnh bau duc (R), b ro, giam phan am lam giam Co bong lng
thau am. Cac c gian sn (mui ten) thay gia cac xng Khong oi
sn. Dau hieu th phat kem theo
Thay oi da
Mach mau vung nach bieu hien nh cac Dan n ong tuyen ,
Day chang Copper b keo thang hoac day len
cau truc hnh ong, thng co nhp ap khi dung
Mc o b ep
sieu am hien th tc th. Doppler duplex hay Cac ac iem Doppler
Doppler mau co the giup khang nh ban chat
mach mau, ac biet hu ch khi d tru sinh thiet
bang kim cac hach lympho hoac khoi vung nach.
Co the thay hach bach huyet vung nach
cung nh ben trong chu mo tuyen vu.27,28 Hach ket qua cu e xac nh vung ron hach co the a b
bnh thng co hnh qua than va co the co vung xam pham, mac du cha b xoa han. Tng t cac
ron m tang phan am (Hnh 23-8). Ve mat sieu am, hach tang san ln len co the bieu hien giong nh
cac hach bnh thng, nho trong giong nh cac hach di can. oi khi co the thay c cac om
tieu thuy m hoac cac nang va khong phan biet phan am kem vung vo hay b vien vung vo hach
c vi fibroadenoma nho.29,30 Khi phat hien vung khong eu gi y s tch tu cac te bao ac tnh. Sieu
ron m cua hach, sieu am khong ang tin cay trong am co the hu ch trong viec khang nh ban chat
viec loai tr ac tnh phu n b ung th vu. Hach hach khi phat hien ron m cua hach ( phan am
kch thc bnh thng b tham nhiem u co the day) ma oi khi b cac mo x tuyen che khuat tren
hien len nh hach bnh thng, phai so sanh vi nhu anh.
Hnh 23-8. Hach bach huyet. A, Sieu am mot khoi hnh trai than, phan am kem (mui ten) vi m trung tam tang
phan am (au mui ten) khang nh s hien dien cua mot not nho trong vu c coi la hach lympho trong mo vu. Tieu
thuy m di da co phan am giam nam pha trc hach lympho va co phan am cao hn mo si tuyen (FG) ben di.
C ngc, P. B, Nhu anh cho thay not tron phan tren cua vu mot benh nhan b benh bach cau. C, Sieu am cho thay
khoi tren la mot hach ln vi o tang am trung tam (mui ten cong). Tham nhiem benh bach cau tm thay khi mo t thi.
Tuyen nhu 761
Hnh 23-9. Doppler mau va phan tch ton thng. A, Tnh trang giau mach mau nang cao
kha nang ac tnh a nghi ng da vao hnh the thay tren nhu anh va sieu am. Mo hoc: carcinoma ong
dan sa tham nhiem khong biet hoa. B, Khoi dang nang phc tap vi cac not thanh kem hien dien
dong. Mo hoc: papilloma lanh tnh trong nang. Nhn chung, hnh anh mach mau tan sinh hoac giau
mach mau lam tang kha nang nghi ng nhng dong thap hoac khong co dong cha the loai tr tnh ac
neu rat nghi ng qua cac ac tnh khac cua u.
PHNG CACH ANH GIA KHOI U VU NANG
Suot trong nhieu nam, ngi ta ngh rang sieu am Nang vu thng gap phu n quanh tuoi man kinh,
khong giup ch g trong viec phan tch cac u co khoang 35 en 50 tuoi. Moskowitz khao sat 593
ng knh nho hn 1 cm. Kinh nghiem s dung khoi tren 1 cm gii han ro phat hien tren nhu anh,
au do phan giai cao khang nh rang sieu am co 50% la nang. Sau man kinh, cac nang thng bien
the phat hien c nang co ng knh 0,2 en 0,3 mat dan, mac du chung co the van ton tai, phat
cm va phat hien c ton thng dang ac co kch trien them, hoac phat trien phu n dung estrogen
thc 0,5 cm va tham ch nho hn na, tuy thuoc hay estrogen-progesteron e ieu tr thay the
vao tan so va o phan giai cua au do, v tr cua u hormone.
ben trong vu, ban chat chu mo xung quanh va ky Mot trong nhng ong gop quan trong nhat cua
thuat quet.5 Mac du hnh anh sieu am cua nhieu u sieu am vu la chan oan tin cay mot nang n
ac thng khong ac hieu, a co nhng tien bo gian. Khong can mot hanh ong lam sang nao khac
trong viec xac nh cac ac iem cua cac khoi ac; neu khoi tren hoi u tieu chuan sieu am cua mot
khong nen n gian hoa qua o rang sieu am ch nang n gian tr khi benh nhan au, nang gay can
c s dung e phan biet nang vi khoi ac. Mac tr kham lam sang hay luc t kham vu hoac cac
du ng b co gai la dau hieu quan trong duy trieu chng khac co lien quan.21
nhat e c oan tnh ac, viec ket hp nhieu dau Tieu chuan chan oan phai c ap dung mot
hieu khac van tot hn la ch mot dau hieu duy cach nghiem ngat, giong nh oi vi cac nang
nhat.13,31 Phan tch ton thng (xem khung trang ni khac trong c the. Ton thng phai:
759), theo benh s lam sang, cac dau hieu nhu anh phan am trong
va tham kham lam sang, tuoi cua benh nhan, yeu tron hoac bau duc
to co nguy c ac tnh, eu co the gi y en mc o b ro (ac biet la thanh sau)
nghi ng ac tnh nao o (Hnh 23-10). ieu nay co dau hieu tang am pha sau
giong nh phan loai BI RADS cua American Neu nang khong cang, ep au do co the lam
College of Radiology (ACR) ve cac bat thng thay oi hnh dang nang. Neu con nghi ng chan
tren nhu anh: oan nang, co ch nh choc hut. Ton thng de b
1. am tnh; e ep co nhieu kha nang lanh tnh hn la ac tnh.34
2. dau hieu lanh tnh; e viec chan oan nang chnh xac, phai lu y
3. dau hieu co ve lanh tnh (can theo doi lai trong moi mat cua ky thuat.12 ieu chnh gain va nang
thi gian ngan); lng song am phu hp vi tng loai may sieu am
4. nghi ng co bat thng (can sinh thiet); va chnh lai cho tng benh nhan khac nhau. at
5. rat gi y en ac tnh.32 vung hoi tu thch hp (Hnh 23-2), dung mieng em
Da tren anh gia nay, co the ngh ti cac cho cac ton thng nong. e boc lo cac ac iem
cach x tr thuan li, bao ton. Cac bc x tr bao cua nang nam sau trong vu hoac trng hp vu ln,
gom ky thuat xam lan qua da e tang o ac hieu can phai e ep hoac thay oi t the benh nhan.
cho chan oan, t o giam toi thieu nhu cau lam Vi viec chnh nang lng song am tang len hoac
phau thuat sinh thiet . bu tr gain theo o sau (TCG), phan
Hnh 23-10. Khoi ac cha xac nh. A,

Thoang nhn, khoi co ng b kha ro va gi y u
x tuyen. U co cau truc phan am khong ong nhat
va giam phan am so vi mo tuyen xung quanh.
Tuy nhien, khao sat can than cho thay ng b
khong eu me ben va sau (mui ten cong), gia
tang nghi ng. Mo hoc cua mau sinh thiet loi la
carcinoma ong tham nhiem.
Tuyen nhu 763
trc cua nang co the lap ay nhng thanh sau cua hnh anh sieu am bieu hien ton thng vu tan sinh
nang van con ro net. Neu hoi u tat ca cac tieu va khong tan sinh. e c oan tnh ac, ket hp
chuan tren, chan oan nang co the chnh xac ti nhieu dau hieu van tot hn la mot dau hieu.
gan 100% va ch can theo doi thng quy.21 Theo Mac du hau nh tat ca carcinoma thay c
kinh nghiem cua chung toi, ti 30% nang n gian tren sieu am la phan am kem (so sanh vi chu mo
co phan am ben trong (Hnh 23-11). Viec x tr cac vu lan can hoac m).5,24 Theo kinh nghiem cua
nang nay kho, neu tat ca cac tieu chuan khac eu chung toi, chung toi cha bao gi thay carcinoma
thoa man ngoai tr s hien dien cua cac phan am nao co phan am ong nhat giong nh mo x tuyen.
ben trong va tren sieu am lai co mot so ton thng Quet than trong, tuy co the thay vien day tang
cung hien len tng t nh vay, co the khong can phan am (Hnh 23-12 ), van hien dien mot vung
phai choc hut va ch can theo doi hnh anh la u. nho giam phan am. o phan am tng oi cua ton
thng phu thuoc phan nao vao dai ong cua may.
CAC KHOI AC VA HON HP Trong sieu am vu, cac ton thng se thay ro hn
trong mot dai bien thien te nh cua thang xam; hnh
ac iem sieu am va cac mc o nghi ng anh trang en tng phan cao se ngan can kha
Carcinom vu la nguyen nhan hang au gay ung nang phan biet mo va xac nh ac tnh ton thng.
th phu n Hoa ky. Cho en gan ay, xuat o Mac du hnh dang va b cua khoi u la cac yeu
van gia tang vi 180.300 trng hp d oan moi to ch iem quan trong nhat cho ban chat lanh ac,
nam.35 Viec phat hien sm nang cao t le song.1 van con cac chong cheo nhau. Du noi chung fibro-
Mot cach ly tng, hnh anh phai cho phep chan adenoma co hnh bau duc, carcinoma cung co the
oan chnh xac carcinoma vu. Mac du mot so dau thon dai va tron. Carcinoma ien hnh co b khong
hieu tren nhu anh va/hoac dau hieu sieu am cho eu, ton thng lanh tnh nh ap xe, hamartoma,
phep chan oan chuyen biet mot so bat thng hoai t m cung co b lm chm. Dau hieu b eu
lanh tnh va ac tnh, van con mot thang rong nhieu ch iem cho fibroadenoma cung co the la dau
hieu cua vai carcinoma vu nguyen phat cung nh
di can vu (Hnh 23-13).13,31,37
Bong lng pha sau, gap trong 40% en 60%
carcinom, la bieu hien cua ap ng tao x do s
hien dien cua u (Hnh 23-12).37-39 Cac u tan sinh
lanh tnh nh fibroadenoma cung co the bieu hien
bong lng sau, v vay dau hieu nay khong ac hieu
cho tnh ac.5,11 Theo chung toi, bieu hien bong lng
khong lien quan ti voi hoa hien dien trong ti
30% fibroadenoma, ac biet nhng u b hyalin
hoa (Hnh 23-14).40 Bong lng con co the i kem
AC IEM SIEU AM CUA CARCINOM VU

IEN HNH
ng b khong eu
Dang tron va truc ln thang goc vi mat da13.36
Phan am giam so vi mo x tuyen lan can va/hoac
mo m
Cau truc phan am khong ong nhat
Hnh 23-11. Nang vi phan am ben trong. Theo kinh
Bong lng pha sau
nghiem cua chung toi, ti 30% cac nang co the co phan am
ben trong, rai rac nh hnh tren hoac giam phan am ong
Vien tang phan am vi o day thay oi bieu hien
nhat hn. Choc hut cac ton thng nay cho chat dch trong, mc lan rong cua u, s tao mo x hoac mo vu
vang nhat hoac xanh am. b e ep
Hnh 23-12. Cac hnh anh sieu am khac nhau cua carcinoma ong tuyen tham nhiem. A, Khoi b
khong ro, hnh dang khong eu, giam phan am so vi cac tieu thuy m xung quanh. Truc ln cua u thang goc vi
mat da. Mot vien day, tang am (mui ten) lam ta chu y ti hnh anh u loi khong eu vao trong mo lan can. Bong
lng sau manh. B, Khoi nho giam phan am (mui ten cong) vi vanh tang phan am boc quanh (au mui ten). Phan
ng tao x keo day chang Cooper (mui ten) vao trong u. Hien dien bong lng pha sau. C, Carcinoma ng knh
0,5 cm, hnh dang khong eu, b gai (mui ten) va thng tron. Bong lng pha sau manh. D, Khoi b a cung nho,
hnh tron, phan am ben trong khong ong nhat kem vien tang phan am (au mui ten) gi y nhieu ti u ac tnh.
Lu y khong co bong lng sau. B a cung nho (mui ten). (A va B trch t Goldberg BB, Pettersson H, ed. The
NICER Year Book 1996: Ultrasonography . Olso: The NICER Institute; 1996.)
Tuyen nhu 765
Hnh 23-13. Di can vu t u nhau hiem gap. Khoi ac, nam nong, giam phan
am, ng b khong eu lam, c sieu am ngay trc khi ban vi kim 14G (au
mui ten) e lay mau loi sinh thiet. Di can en vu khong phai khong thng gap n
oc va gii han ro. C ngc , P.
Day da va phu co the ong ngha vi ung th

vu v viem, nhng cung co the xay ra khi viem vu,
ap xe, xa tr, va benh toan than nh suy tim
huyet (Hnh 23-15). Mac du sieu am khong cho
phep xac nh nguyen nhan ac hieu, dau hieu da
day rat de anh gia vi sieu am phan giai cao.
ng trong cua hai ng da song song nh
thng thay oi khi b gian oan hoac bien mat.
Chan b dayb tham nhiem, x hoa hay phuco
phan am tr nen cao hn thng gap la phan am
kem. oi khi, sieu am co the cho thay cac mach
bach huyet tre hay tu dch mo ke phan bo ngau
nhien. S giam dan be day cua da co the c theo
Hnh 23-14. Fibroadenoma hyalin hoa. Khoi b ro,
doi bang sieu am nhng benh nhan ang c xa
dang thon (mui ten) vi b trc a cung ro. Hien dien bong
lng sau, thay trong 30% cac u x tuyen khong voi hoa tr ma tuyen vu cua ho rat kho e ep u e chup
nhng theo kinh nghiem cua chung toi thng b hyalin hoa. nhu anh.44,45 Neu da day va phu mo vu khong
Du u ang am vi cac tieu thuy m lan can, hng cua u thuyen giam hoac khong giai thch c, nh benh
khac vi mo lan can.
nhan ang c xa tr v ung th vu, co ch nh
sinh thiet vu vi vui mach bach huyet da e loai
tr carcinom viem.25,46 Theo kinh nghiem cua
vi hoai t m, tao seo sau phau thuat va sau chan chung toi, sieu am co the phat hien khoi u b lan
thng, trong x seo lan toa, u hat, benh hach x trong mo phu phu n b ung th vu viem. Co the
cng khu tru va x hoa, x hoa do tieu ng, ap chan oan mo hoc bang sinh thiet loi di hng
xe cha kh.41-43 Mo bnh thng cung co the gay dan cua sieu am va khoi u tm thay hau nh la
bong lng pha sau khi au do lt qua be mat mo carcinoma ong tuyen tham nhiem.25,46
cong vi nhieu giao dien cua day chang Copper va Dan ong tuyen khong oi xng, mot dau hieu
cac vach ngan mo lien ket khac, cac tieu thuy m khong may ac hieu cho ac tnh, co the la bieu
va chu mo tuyen vu. hien cua carcinoma, nhng thng la bieu hien cua
Hnh 23-15. Phu tuyen vu: suy tim huyet. A, Phu mo ke va day da. Nhu anh the tren-di cho
thay ben trai (L) ln hn ben phai (R). B, Day da (au mui ten) vi nhng khoi tu dch dang thang, phan
am trong, phan nhanh khong giong nh cua ong dan sa (mui ten cong) bieu hien cac mach bach huyet
tre hoac tu dch khoang ke mot phu n 73 tuoi b suy tim huyet. Tnh phan am sang cua mo cha
dch khoang ke la ac tnh cua phu. Hnh anh hoc theo doi sau khi hoan tat ieu tr noi khoa cho thay
phu bien mat hoan toan. (A va B trch t Goldberg BB, Pettersson H, ed. The NICER Year Book 1996:
Ultrasonography . Olso: The NICER Institute; 1996.)
Tuyen nhu 767
ton thng lanh tnh nh papilloma trong ong dan kinh nghiem cua chung toi, a so cac u nay biet
sa. Tr khi co nhng thay oi t lan khao sat hoa kem ve mat mo hoc (xem Hnh 23-16).
trc hoac co tiet dch num vu, ngi ta khuyen Carcinoma tieu thuy tham nhiem. Xep th
nen theo doi nh ky hn la sinh thiet.47 hai ve xuat o nhng t hn nhieu so vi carcinoma
Voi hoa ln hien ro tren sieu am nh nhng o ong tham nhiem, chiem khoang 8% en 10% ung
tang phan am, thng kem bong lng pha sau. th vu.51 Xu hng xay ra hai vu va a o dao
Nhng chum voi hoa nh bap rang gap trong ong t 6% en 36%.52 Mac du tren nhu anh co the
fibroadenoma. ong voi tho cung co the gap trong khong phan biet c carcinoma tieu thuy xam lan
hoai t m, trong cac vung tao seo, trong hach vi hnh anh cac khoi b gai cua carcinoma ong
lympho lien quan ti cac benh u hat va trong cac tham nhiem, chung thng co bieu hien cua mot
ton thng khac. khoi b khong ro, am o tang khong oi xng,
Voi hoa nho li ti khi tap trung khong eu va a khong eu va co the giam am o.53-56 Cac te bao
dang la dau hieu quan trong nhat tren nhu anh e u phat tan theo ng thang xuyen qua chu mo vu
chan oan ung th khong s thay c, ac biet la ma khong co nhan u trung tam. Bieu hien tren nhu
carcinoma trong ong dan sa.4,7,48 ng knh cua anh cho thay ac iem mo hoc nay. ac biet la
tng om voi hoa nho nay t 0,1 en 0,4 mm. oi tren cac vu day hay vu ma u ch bieu hien nh
khi, vi sieu am phan giai cao cung co the thay mot vung roi loan cau truc khong ro ret, sieu am
c voi hoa nho, nhat la khi no nam trong khoi u co the anh gia chac chan khoi u tham nhiem, oi
(Hnh 23-16).5,37 Voi hoa li ti c tm thay khong khi rat ln ma khong the hien tren nhu anh nhng
thng xuyen, hien len nh nhng om tang phan tren lam sang nghi ng mot vung cng m ho
am, nho li ti trong chu mo vu va thng kho phan (Hnh 23-17). Tren sieu am, cac u giam phan am
biet vi cac be mat sinh am khac. Nhng ong voi nay co hnh dang khong eu, b khong ro, oi khi
nho thng khong sinh bong lng. Viec xac nh co vanh phan am day, kem bong lng pha sau, va
ac iem hnh thai cua voi hoa nho hien tai nam lam bien dang cac mo xung quanh .
ngoai kha nang phan giai cua cac thiet b ang co, Carcinoma tuy. Carcinoma tuy chiem khoang
va viec c oan so lng va mc lan rong cua voi 5% ung th vu.49 Co tan suat cao phu n di 50
hoa li ti van cha ang tin cay. tuoi.49 Tren nhu anh, cac u nay co the ln, ng
b tng oi ro. ng b ro net va phan am ben
Cac khoi u ac tnh trong ong nhat cua carcinoma tuy lam bieu hien
Carcinoma ong dan sa. Carcinoma ong tren sieu am giong nh mot nang, can chu y can
tuyen tham nhiem chiem khoang 80% ung th vu.49 than ti cac vung khu tru va ieu chnh gain co the
Phat sinh t bieu mo ong cac thanh phan ong giup tranh nham lan nay. Cac u tuy co the tron, b
kch thc trung bnh va nho hn, carcinoma ong a cung, ong nhat hoac giam phan am va co the
tuyen tham nhiem co the co cac loai mo hoc khac co tang am pha sau.37.38.53 Co the nhn thay ro
nh carcinoma tieu quan hoac tieu thuy xam lan. 49 phan am ben trong u du at gain cao giup tach biet
Khi s cac khoi u nay ta co cam giac chung ton thng nay vi nang n gian. Mot so cho b
ln hn nh thay tren nhu anh va sieu am. Hien khoi u co the khong eu hn la lang (Hnh 23-18).
tng pho bien tren lam sang nay co the c giai Cac dau hieu nay co the m ho va can choc hut e
thch bang phan ng tao mo x do khoi u. Tren nhu phan biet carcinoma tuy vi nang hoac ap xe.
anh, khoi u nay thng co ng b khong ro va Carcinoma dang nhay (the keo). La mot the
khong eu phan anh ban chat tham nhiem cua khoi khong pho bien cua ung th vu, chiem khoang 1%
u va ap ng x hoa do s hien dien cua no. Tng en 2% ung th vu.38 Carcinoma nhay co d hau
t, hau het carcinoma ong xam lan hien len tren tot hn carcinoma ong tham nhiem.25 Bieu hien
sieu am vi b khong eu va khong ro.13,50 Cac giong nh carcinoma tuy ca tren nhu anh lan sieu
khoi u nay thng ac, khong ong nhat, phan am am nhng thng xay ra phu n ln tuoi.49 Hnh
giam va lam giam thau am. Tuy nhien, hnh anh anh sieu am la mot khoi giam phan am, ng b
sieu am benh ly ac tnh thng gap nay bien tng oi ro, cau truc ong nhat, khong co giam
thien rat nhieu. V du, mot vai carcinoma ong tham am co y ngha pha sau (Hnh 23-19). ac iem
nhiem co b ro va khong lam giam thau am . Theo tren phan anh lng mucin ln thay tren vi the.
Hnh 23-16. Carcinoma ong dan sa tham nhiem, biet hoa kem. A, Khoi s c a xac
nh bang marker can quang, dang tron, b a cung nhng gap goc ro net (au mui ten) thay tren nhu
anh the nghieng. B, Sieu am cho thay mot khoi ac giam phan am, khong ong nhat (mui ten cong) vi
ng b ro va a cung. Tang am pha sau noi bat carcinoma ong tham nhiem biet hoa kem nay. Voi
hoa li ti nam lan trong khoi u, nh cac au mui ten.
Tuyen nhu 769
Hnh 23-17. Carcinoma tieu thuy xam lan: thng b bo sot tren lam sang va tren nhu anh. A,
Hnh chup hai vu the tren-di cho thay mot phan mat o m dang not (mui ten) trung tam pha sau vu phai. B,
Hnh phong ai vi chen ep tai cho cho thay mot vung nho (mui ten) mat o nhu mo trong vung nep di vu tng
ng vi not thay tren the tren-di. C, Sieu am tai vung bat thng thay tren nhu anh cho thay vung cau truc roi
loan (AD) giam phan am, gii han khong ro kem tham nhiem (mui ten) vao nhu mo si tuyen lan can (F). Sinh
thiet loi di hng dan cua sieu am khang nh chan oan carcinoma tieu thuy tham nhiem. D, mot benh nhan
khac t kham thay day m ho, nhu anh cho thay mo tuyen day, tang mat o nhng khong co khoi u. Sieu am cho
thay mot khoi goc canh (M) lan rong, phan am giam chiem gan het hai phan ba vu. Mo si tuyen, F.
Carcinoma tieu quan. Xuat o gan tng a minh chng ve s ket hp gia carcinom tieu
ng vi carcinoma nhay, dang n thuan, cac u quan va seo lanh tnh hnh nan hoa.56
tan sinh t gap nay co tien lng rat kha quan. Ve Carcinoma nhu. Xay ra thng nhat phu n
mat nhu anh va sieu am, cac u nay bieu hien la man kinh, ay la nhng u hiem gap, co the co gii
nhng khoi nho, b khong eu vi cac mc o han ro tren sieu am, co tien lng tot, ac iem
khac nhau. oi khi tren nhu anh, co the thay c giong nh carcinoma nhay hay tieu quan.57-59
cac gai dai i kem khoi u nho nhng ac iem sieu Carcinoma nhu co the nam hoan toan trong ong
am khong chuyen biet (Hnh 23-29).54,55 Ngi ta dan sa hoac co nhng vung xam lan.60 Co the
nghi ng tren lam sang khi au vu tiet dch nh

mau, mac du dau hieu nay thng ong ngha vi
s hien dien cua u nhu lanh tnh trong ong dan sa
(xem Hnh 23-5, B). Ve mat sieu am, carcinoma
nhu co the hien len di dang mot khoi ac hoac
hon hp hoac vi mo ac loi vao trong nang (Hnh
23-21).61-63
CAC KHOI U LANH

Fibroadenoma. Mac du fibroadenoma xuat
hien moi la tuoi, khoi u thng gap nhat phu
n di 30 tuoi hoac 35 tuoi la u x tuyen. Khoang
10% en 20% trng hp64,65 nhieu u va khoang
3% hoac hn co u hai ben. Mac du cung a tm
thay carcinoma ong va tieu thuy trong hay gan
fibroadenoma, hau het u khong lam tang nguy c
phat trien ung th vu.66 Tuy nhien, fibroadenoma
phc tap gom nang, benh hach x cng va cac bien
oi nhu ly tiet lam tang nguy c gap 3 en 4 lan.66
ac iem sieu am cua fibroadenoma rat thay
oi, nhng nhn chung, u co phan am giam so vi
chu mo si tuyen va ang am vi tieu thuy m
Hnh 23-18. Carcinoma dang nhay. Hnh sieu am phat trong vu (Hnh 23-22).22 Hau het cac u ong nhat
hien mot khoi a thuy (mui ten) vi ng b khong ro, co
nhng theo kinh nghiem cua chung toi, thng gap
cac phan am ben trong va mot vung nho tang am pha sau.
nhng vung khong ong nhat. Thng u hnh bau
Hnh 23-19. Carcinoma nhay (the keo). A, Nhu anh chen ep tai cho mot u s c (a anh
dau bang marker can quang). Not ve tnh thay me ngoai gi y mot tui tha (mui ten cong). B,
Sieu am mot phan u rat tng ng vi nhu anh: ng b ro net, thay ca not ve tinh (mui ten cong)
dang tui tha. Khoi ong nhat nay bieu hien tang am pha sau.
Tuyen nhu 771
Hnh 23-20. Carcinoma tieu quan. A, Hnh nhu anh phong ai cho thay khoi vi trung tam
thau quang va nhng gai b vn dai gi y seo nan hoa. B, Sieu am phat hien khoi ac giam
phan am, 0,7 cm ng knh, ng b khong eu va khong ro (mui ten) va giam thau am pha
sau, ac tnh thng gap cua carcinoma.
Hnh 23-21. Carcinoma dang nhu. A, The chech trong-noai cua vu trai cho thay mot khoi gii
han ro va mat o ben trong tang. Co the ng b phan nao khong eu (mui ten). B, Khoi phc tap,
gii han ro vi mau nho pha trc (mui ten cong). Vung trung tam tang am, bao vong quanh co ve
la thanh phan dang nang (C). Carcinoma nhu in situ kem xam lan mo em.
duc va gii han ro va ng b a cung ln.13,36 phu hp vi fibroadenoma. Mot bao cao giai
Trong 50 khoi fibroadenoma hoi cu, tat ca eu co phau benh khong co te bao ac tnh khong co
hnh bau duc t nhat tren mot mat cat; khong co ngha la lanh tnh v co the sai sot ve ky thuat,
khoi nao tron tren ca hai mat cat.41 Lu y truc ln khong choc ung khoi u cung co the cho ket qua
cua fibroadenoma nam song song vi be mat tng t.
da.13,36 Hnh thai giam thau am pha sau cung thay U diep the (phyllodes). Mot khoi u ln, gii
oi, hau het chung tang am nhe pha sau, nhng han ro, co thuy, phat trien nhanh phu n tren 30
khoang 30% co bong lng khong do voi hoa.68 tuoi gi y kha nang u diep the. Trong hn 40% so
Viec x tr lam sang mot u ngh la fibro- benh nhan co fibroadenoma kem theo.65 Cac the ac
adenoma tuy thuoc vao bieu hien lam sang.10,69 tnh cua u diep the (co the di can) c xac nh
ngi tre va phu n ln tuoi khi khoi u khong phai bang mo hoc qua mc o gian phan qua 5 en 10
la mi va thoa man vi kha nang can nguyen lanh lan tren moi th trng gan.65 Khoi u ac nay co
tnh cao, e ngh theo doi trong khoang thi gian hnh anh sieu am khong ac hieu. Cau truc phan
ngan vi khao sat nh ky ( nh 6 thang ) hn la cat am ben trong khong ong nhat, co tang am pha
bo. Trong theo doi, nen sieu am hn la nhu anh. sau va thay nhng khuyet giam phan am.70
Viec quyet nh ieu tr phai tuy vao benh nhan va Fibroadenoma khong lo. Nhng u tan sinh t
theo mc o lo lang cua benh nhan. Neu benh gap nay c xac nh bi kch thc ln, ien
nhan khong yen tam, co the phai choc hut bang hnh t 5 en 10 cm ng knh.59,65 Neu khoi u
kim nho hay lay loi bang kim ln e lam tang nay xay ra tre gai cho ti tuoi day th hoac
mc tin tng vao ket qua la fibroadenoma hoac phu nu tre, co the goi chung la fibroadenoma
Hnh 23-22. Fibroadenoma: cac hnh thai a dang. A, Khoi

hnh bau duc, giam phan am, truc ln song song mat da. ng b
mong, ro net, hi nhap nho pha trc (mui ten cong). Ben trong hien
dien vai o nho sinh am. Pha sau khong thay tang am hoac bong lng.
Ton thng cho thay tnh chat cua phan ln u x tuyen. B, U x tuyen
nho co ong voi (mui ten) vi cac tieu thuy m (FL) bao quanh vi mot
vung nho mo si tuyen lan can (au mui ten). U x tuyen va tieu thuy
m ang am va hnh dang tng t; voi hoa giup phan biet khoi u vi
mo m bnh thng. C, U x tuyen ien hnh vi vo bao mong, tang
am, hng song song mat da kem khe (mui ten), tang am nhe pha sau,
cau truc ben trong phan nao khong ong nhat. Nhn chung, u x tuyen
va cac tieu thuy m quanh no co o phan am giong nhau.
Tuyen nhu 773
ngi tre (juvenile fibroadenoma). Phan biet cac u Thng ch co mot u mac du co the co nhieu khoi
nay vi u dep the nh vao yeu to benh nhan tre va ca hai ben. Hnh thai sieu am giong nh mot
(11 en 20 tuoi), khong co kha nang ac tnh, mac fibroadenoma ln vi tang phan am ben trong t
du s tang trng nhanh co the gi y ac tnh. thap ti trung bnh va b ro nh net but ch (Hnh
23-23).
Hnh 23-23. Fibroadenoma khong lo (ngi tre)

benh nhan 15 tuoi. A va B, Nhu anh hai vu cho thay
nhieu khoi ln, hnh bau ducgii han ro va nhng vung voi
hoa co ve lanh tnh. C, Hnh sieu am cua mot trong nhng
khoi tren cho thay khoi co phan am giam (mui ten) vi nhng
phan am hi tang ben trong va phan nao tang am pha sau,
be day da pha tren bnh thng.
X hoa khu tru. La mot bat thng tiem an t

gap ch khoang 10% so vi carcinoma.71 Nguyen
nhan cha ro nhng co the lien quan ti nhng
bien oi sau viem hoac mach mau. Tren nhu anh,
ton thng co mat o mo mem gii han ro, dang
a. Thng mot ben b cua no co goc canh, con
ben con lai nh lan vao chu mo vu lan can (Hnh
23-24).72 Trong 8 ca chung toi khao sat, hau het
hien len di sieu am nh ton thng gii han ro,
hnh ellip, giam phan am, khong thay oi tnh thau
am pha sau.72 Nam hoac sau ca gan ay cung co
ac iem tng t. Mot tac gia khac a bao cao
mot trng hp x hoa khu tru co phan am tang va
co bong lng sau.73 Phai phan biet x hoa khu tru
vi x hoa do tieu ng xay ra ngi tieu
ng phu thuoc insulin lau ngay. Tren sieu am,
x hoa do tieu ng giong nh ac tnh va ac
trng bi nhng khoi giam phan am vi b khong
eu, lm chm kem bong lng pha sau.74
Hamartoma ( u x-m-tuyen ). Hamartoma
hay fibrolipoadenoma la mot u lanh hiem gap cha
mo si, bieu mo va mo m.75 Hamartoma ln co
the phan thuy, bieu hien giong hnh bong cai tren
nhu anh. Cac ton thng nho hn co hnh bau duc,
gii han ro va cha cac o mo m. Nhu anh cho
thay mot khoi co vo bao, thau quang mot phan hay
toan bo tng ng vi u lanh tnh cha mo m nh
Hnh 23-24. X hoa cuc bo. A, Hnh nhu anh chech hamartom hoac u m. Tren sieu am, hamartoma co
trong-ngoai cho thay hnh m dang a phan di cua vu cau truc khong ong nhat vi nhng phan tang
(mui ten). B, Tren sieu am, khoi (mui ten) cung co dang a phan am bieu hien mo m va co the co giam thau
vi ac iem lanh tnh, giong fibroadenoma
am pha sau (Hnh 23-25).76
Hnh 23-25. Hamartoma. A, Nhu anh phan tren vu cho thay mot khoi m (mui ten cong) nh co vo bao cha ben trong
mot thanh phan mat o mo mem co ve lanh tnh (au mui ten). B, Khoi b ro, khong ong nhat (mui ten) tren sieu am vi
cac thanh phan tang am bieu hien m. Cung co the hien dien nhng u dang nang (C) va cac loai lanh tnh khac. (Trch t
Goldberg BB, Pettersson H, ed. The NICER year Book 1996: Uktrasonography. Olso: The NICER Institue; 1996.)
Tuyen nhu 775
Lipoma (u m). Lipoma xay ra phan ln phu U nhu (papilloma). Papilloma la mot u tan
n ln tuoi, tren nhu anh la nhng u thau quang va sinh phat sinh t s tang sinh bieu mo trong ong
co vo bao mong. Tr khi tang trng nhanh, gay dan sa va papilloma la nguyen nhan thng gap
kho chu hoac co bieu hien lam sang khac, oi vi nhat cua tiet dch num vu co mau.77 Ngi ta
cac u lanh tnh cha m nh hamartoma va lipoma khong ngh rang papilloma trong ong dan sa n
ch can theo doi thng qui. ac iem cua u m oc lam tang nguy c ung th vu.25 Tren nhu anh,
tren sieu am la co vo bao mong, tnh phan am thay papilloma nh la cac vung mat o mo mem
trung bnh, cau truc ong nhat, (Hnh 23-26), mac co gii han va thng ket hp vi gian ong sa
du sieu am khong can thiet trong anh gia chan dang chuoi hat vung sau quang vu. Tren sieu am,
oan lipoma hay cac u cha m khac. chung la cac khoi ac gii han ro hoac la cac nang
Nang ba nhn (vui) . oi khi c goi la cha mo ac ben trong, giong nh hnh anh
nang vui bieu b (epidermal inclusion cyst), thng carcinoma nhu dang nang (xem Hnh 23-5, B va
khong co trieu chng tr khi no ln len hoac b 23-9, B)
nhiem trung. V tr thng nep di vu, vung Nang sa. Nang sa la khoi dang nang cha
nach hay phan trong nhat cua vu. Kham lam sang sa. Chung la tnh trang gian n dang nang cua cac
co the thay cho lom hnh ron tren da ni co ng ong dan sa xay ra trong hoac sau thi ky cho con
thong vi khoi tu m di da. Tren nhu anh, cac bu va benh s lam sang cho d kien e chan
ton thng nay co gii han ro net va mat o cao, oan.78 Tren nhu anh, chung la nhng khoi gii
va can phai phau thuat lay i va boc tach vo bao. han ro ket hp mat o mo mem va thau quang, co
Tren sieu am, cac khoi giam phan am nay co gii the la bieu hien cua ban chat cha m cua sa. Co
han ro, co cac phan am rat kem rai rac ben trong the thay mot mc dch-m tren hnh nhu anh the
va tang am pha sau (Hnh 23-27). Vai trng hp nghieng 90% (tia nam ngang). Hnh anh sieu am
co chum trung tam tang phan am. Nang ba nhn khong ac hieu va nhieu tai lieu bao cao rang
nhiem trung cho bieu hien b khong eu va co the nang sa co hnh anh rat thay oi nh la cac ton
kem vi day da. Chung co the giong carcinoma thng sinh am hoac cac ton thng dang nang ma
nong . tnh thau am kem hn nang n gian.73,79 Theo kinh
Hnh 23-26. Lipoma. A, Nhu anh chan oan lipoma cho thay
mot khoi ln thau quang (mui ten), pha tren phu cac thanh
phan nhu mo tuyen. B, Sieu am cho thay khoi ln tang phan
am, ong nhat (mui ten) co vo boc mong bao quang.
nghiem cua chung toi, nang sa bieu hien mc ng, s dung corticoid va cac tnh trang c che
dchdch, phan am ben trong mc thap va chat mien dch khac (Hnh 23-29). Cho tray da trong
can ri xuong ni thap nhat khac han vi cac nang eczema nang co the la ngo vao cua tac nhan
n gian (Hnh 23-28). nhiem trung. ac iem sieu am thay oi t khoi
Ap xe. Ap xe thng xay ra ngi cho con hon hp vi b khong eu ti ton thng hnh bau
bu va Staphylococcus aureus la tac nhan gay benh duc gii han hi ro vi phan am rat kem ben trong
thng gap nhat.80 Co the gap phu n ln tuoi va tang am pha sau. Choc hut bang kim giup
nh bieu hien cua viem vu quanh ong sa hay cua khang nh ap xe cung nh anh gia no va sieu am
nang nhiem trung. Ap xe thng nam vung sau theo doi sau ieu tr e biet a het han cha. Neu
quang vu nhng cung co the nam xa num vu hoac ton thng khong giam, co the ch nh sinh thiet
phu n co san cac bat thng khac nh tieu e loai tr nguyen nhan ung th tiem an.
Hnh 23-27. Nang ba nhn hoac nang vui bieu b. A, Mot khoi hnh bau duc, b eu
ro, hng song song vi mat da va nam rat nong, tang am pha sau, ben trong co nhng phan
am tu lai vi lam sang oi chieu cho phep nhan nh la nang ba nhn. B, Nhu anh cung ac
trng v khoi b ro, eu, mat o cao nam ngay di da. Marker can quang chng to u s thay
c.
Hnh 23-28. Nang sa. Mc dch-dch thay trong mot khoi di ong, khong au, gii han ro,
dang nang, cha ay sa. Choc di sieu am hng dan hut het toan bo. (Trch t Mendelson
EB, Tobin CE. US-guided interventions: fine-needle aspiration and large-core needle biopsy.
RSNA Categorical Course in Breast Imaging: 1995:139-149.)
Tuyen nhu 777
Seo hnh nan hoa. Seo nan hoa khi ln c

biet di ten ton thng x cng phc tap,
tren lam sang khong s thay, kch thc thay oi t
vi the ti vai cm va tren nhu anh va sieu am, hnh
anh giong nh carcinoma vu b gai.25 Co the hien
dien voi hoa li ti. Tren nhu anh, cac ton thng
thoai hoa an hoi nay vi cac ong tu vao trung tam
co the co vung thau quang trung tam gi y cho
chan oan. Tren sieu am, seo nan hoa co the co b
khong eu va bong lng pha sau (Hnh 23-30).81
Cac ton thng nay co the la ket tu cac mo hoc
tang sinh va thng i kem vi carcinoma tieu
quan.56,82 Tang san ong tuyen khong ien hnh va
Hnh 23-29. Ap xe. Khoi phc tap (au mui ten) phat trien carcinoma ong tuyen tai cho cung a c ghi
sau num vu mot phu n tre a th choc xuyen qua quang
nhan trong trng hp co seo nan hoa, cac benh ly
vu. Choc hut qua da di hng dan cua sieu am va ieu tr
khang sinh giup lam bien mat hoan toan. nay can phau thuat cat bo toan bo hn la ch lay
mau.25
Hnh 23-30. Seo hnh nan hoa (radial scar). A, Hnh phong ai vi chen
ep tai cho the tren-di cho thay mot vung co b gai (mui ten) kem mot so cho
thau quang. B, ng b khong eu va hnh dang (mui ten cong) cung nh bong
lng nhe pha sau gi y ti carcinoma vu nguyen phat. C, Thc hien sinh thiet loi
va ket qua benh hoc gi y seo hnh nan hoa. Thay kim (mui ten) ben trong ton
thng. V cac ton thng tang sinh rat a dang, co the loai tr DCIS hoac
carcinoma ong tuyen. Nhng ton thng nay phai c cat bo toan bo v sinh
thiet loi va FNAB co the bo sot nhng phan ang lu y cua nhng ton thng
phc tap nay.
CAC THU THUAT SIEU AM CAN THIEP phai c choc hut di hng dan cua sieu am.
Cac phan am kem thng hien dien trong nang va
Ch nh va nguyen ly tong quat mac du trong nhieu trng hp, ton thng c
Bat ky ton thng n oc nao khong s c tren nhan nh la nang nhng van can choc hut e
lam sang ma co bieu hien nh nang nhng khong khang nh chan oan. Neu thay s chuyen ong
thoa man het cac tieu chuan sieu am cua nang cua cac phan am ben trong khi e ep hay khi thay
oi t the benh nhan, chan oan nang cang c
cung co. Trieu chng se giam khi choc hut cac
CH NH CHOC HUT NANG VA KHOI nang gay au hoac cang.21
DANG NANG QUA SIEU AM Van co tranh luan ve s can thiet phai xac
nh ac iem bang sieu am oi vi u s thay c
Khoi khong u tieu chuan cua nang n gian (Hnh cung nh s can thiet cua sieu am hng dan trong
23-31) viec choc hut cac khoi s thay a ngh la nang.83
Nang khong s thay nhngco trieu chng hoac nang Ngi e xuat choc hut qua s nan cho rang viec
s thay ma can hut e anh gia . a kim vao khoi u co the kinh te hn va e chan
Nghi ng ap xe hoac nang nhiem trung oan va e ieu tr (xem Hnh 23-32). Y kien tan
Nang s thay hay khong s thay ma can co hng thanh s ho tr cua hnh anh hoc e cap en tam
dan cua hnh anh hoc e tranh bien chng ( nh
quan trong cua viec choc hut nang tron ven cung
vu qua ln hay sang thng gan thanh ngc) .
nh trong viec thay c lien tuc ng i cua kim
bao am s an toan. Hng dan bang hnh anh hoc
Hnh 23-31. So sanh nang n gian va nang phc

tap: s quan trong cua ky thuat. A, Nang ln hoi u cac
tieu chuan cua mot nang n gian. Dai phan am pha trc
(mui ten) la anh gia a am phan hoi. at vung hoi tu trng
gan, co the nham mot nang nho n gian thanh mot nang phc
tap hoac ton thng ac. B, Nhu anh hai vu the chech trong-
ngoai cho thay mat o mo cao dang not. Bat thng s c
nam phan tren cua vu phai (P). C, Sieu am vung tren cho
thay mot o mo phc tap vi ong dan (au mui ten) va nhng
nang nho (C) vi mo tuyen tang am bao quanh (mui ten). Cam
ngh chung la u nhieu kha nang lanh tnh. Mac du choc hut va
sinh thiet loi a chan oan, benh nhan yeu cau c mo va
mo hoc cho thay gom benh dang nang man tnh, tang san ong
va benh hach x cng.
Tuyen nhu 779
ac biet quan trong oi vi ton thng nam gan hut se cho nhan xet a hut het hoan toan hay van
thanh ngc, tan ben trong hay tan ben ngoai con dch ton lu. khoi u co con thanh phan ac sau
tuyen vu, gan nach, hoac nang nhng benh nhan khi hut khong. e chng minh ton thng la ac,
co ghep silicon. Nang co trieu chng khong s thay can gi chat hut e phan tch te bao hoc hoac xem
can c choc hut vi hng dan cua sieu am hay xet choc sinh thiet loi. Khi benh nhan hoac thay
phng tien hnh anh hoc khac. Sieu am sau choc thuoc khong chap nhan theo doi cach quang trong
thi gian ngan, co the thc hien sinh thiet loi cac
trng hp co kha nang lanh tnh.
Lay mau mo qua da. Co the tien hanh e
chan oan cac khoi ac co ac iem cha xac nh
CH NH CUA LAY MAU MO CUA
hay cac ch nh khac (xem khung ben).
KHOI AC QUA DA
Cac thu thuat qua da c chuong hn so vi
Thay the phau thuat sinh thiet ch e chan oan phau thuat sinh thiet khi can phai giam so lng
Ton thng gi y nhieu la ac tnh ( loai 5 theo BI- cac thu thuat hay khi gia thanh va t le bien chng
RAD TM loai 5)49 can co bien phap ieu tr thch t hn so vi sinh thiet m va o tin cay cung cao
hp hn.84 Neu mot u b gai thay tren nhu anh cua
Nhieu khoi khong xac nh hoac nghi ng can xac benh nhan khong co tien can phau thuat hay chan
nh hoac loai tr tnh a o thng vung o va co the la carcinoma tham
Cac khoi nghi ng ( loai 4 theo BI-RAD TM)49 nhom nhiem, benh nhan va phau thuat vien co the chon
quan trong nhat co xuat o ac tnh rong t 25% cach ieu tr bao ton vu ma khong co chan oan
en 90% (xem Hnh 23-10)
trc bang mo hoc qua ky thuat cat lanh. ay
Khoi u co the lanh tnh (loai 3 theo BI-RAD TM)49
sinh thiet bang kim lam gia tang hn la lam giam
nhng benh nhan qua lo lang va can lam thu
thuat e khang nh lanh tnh . so lng toan bo cac thu thuat. V tr co nghi ng
cao trong chan oan hoac s phat tan a o te bao
ac lam cho benh nhan khong u ieu kien ieu tr
Hnh 23-32. Khoi mau tu sau choc hut nang. A, Nang n gian, au, oc hcoc hut di hng dan cua
sieu am. B, nang lai ay ch trong vong vai phut mac du a c ep. Xuat huyet mi (H) hien len nh khoi ac.
Hai thanh phan nang (*) van con. Can 2 tuan khoi mau tu mi tan het, ngan can viec chan oan nang n gian.
e tranh m ho chan oan gay lo lang (co the dan ti nhng can thiep khong can thiet), phai chan oan hnh
anh nhng khoi u trc khi tien hanh choc hut.
Sau khi benh nhan vao t the thch hp, tay

CAC BIEN CHNG CUA THU THUAT CAN THIEP trung vu bang con va betadin (povidon iodin;
DI HNG DAN CUA SIEU AM Purdue Frederick, Norwalk, Conn.). Tay trung au
do bang con; tuy nhien, khong c ngam vao con.
Chay mau
Hanh ong: lay benh s s dung chat khang ong hoac
Neu nha san xuat a lu y khong c dung con,
aspirin lau ngay, hoac loan tao mau; thao luan vi co the boi len be mat va can au do mot dung dch
thay thuoc viec ngng ngan ngay thuoc tren (nh nh Cidex (Johnson and Johnson, Arlington, Tex.).
coumadin); lay phan tch xet nghiem tng benh Mac du mot so bac s thch boc au do bang mot
nhan cu the
bao plastic vo trung, thc ra khong can lan the neu
Nhiem trung
Hanh ong: cho benh nhan biet la nhiem trung co kha thc hien can than cac bc nen tren.86 Boc au do
nang xay ra nhng khong thng xuyen khi lam thu co the lam giam chat lng hnh anh, gay kho khan
thuat can thiep vu (khang sinh d phong oi vi cho thao tac tay va dung cu tc kho hoan tat thu
benh nhan b thap tim hoac sa van hai la). thuat. Ngi lam va ngi phu phai mang gang,
au khu tru
Hanh ong: cho benh nhan biet la au va bam mau
trc tien la bao ve cho chnh ho.
thng xay ra, thng khong lan rong, cho ho biet da Ky thuat a kim qua da. Khong co phng
co the bac mau va hi kho chu va nen dung thuoc phap chnh xac oc nhat giup thc hien va ky thuat
khang viem khong steroid hoac acetaminophen; cho co nguyen tac tng t nh choc hut bang kim nho,
benh nhan ap nc a ngay sau thu thuat
nh v trc mo va sinh thiet loi. Chon ky thuat
Tran kh mang phoi
Hanh ong: s dung ky thuat i kim vao theo truc nho tuy theo v tr va ban chat cua ton thng (Hnh 23-
cua au do, khi okim vat ngang qua chum song am 33). oi vi vu ln, nhieu m, ton thng nam sau,
doc theo truc ln cua au do (xem Hnh 23-33); tranh co the choc hut, sinh thiet va nh v di hng
i qua doc nhat la me trong vu va gan thanh ngc ni dan cua chup nhu anh (nh v ba chieu hoac dung
o, mang phoi cach kim choc hut mot khoang rat
ngan.
tam ep) de hn di sieu am. e an toan, choc hut
cac ton thng gan thanh ngc hoac gan vo manh
Trch t Mendelson EB, Tobik CE. US-guided interventions: fine- cay, trong suot qua trnh lam phai luon nhn thay
needle aspiration and large-core biopsy. RSNA categorical Course
in Breast Imaging; 1995:139-149
kim.
Trong ky thuat a kim vao t truc nho cua
au do (song song vi chum song am), khoi u nam
bao ton, co ch nh sinh thiet loi bang kim ln tren bat c cho nao doc chieu dai cua au do (xem
hoac sinh thiet choc hut bang kim nho. Hnh 23-33, A). Mat phang i vao cang nam ngang,
cang thay ro ca chieu dai kim. ieu quan trong la
Chuan b benh nhan, dung cu va ky thuat au kim khong c lech ra ngoai chum song hep.
Mot khi co yeu cau thc hien thu thuat qua da, can Neu nghieng kim qua ben nay hoac ben kia thay v
xem xet tnh hieu qua, an toan, tien li va gia chnh gia, se khong thay au kim na. Neu ton
thanh cua thu thuat. Khong mot phng phap chnh thng nam sau, nen nh v ton thng mot
xac nao e thc hien thu thuat va thu thuat at kim khoang cach nao o tnh t iem vao cua kim, nh
bang tay di hng dan cua sieu am co cung o co the i vao ngang hn. Co the nh v ton
nguyen ly nh thu thuat choc hut kim nho ton thng nong gan mat au do va co the hng kim
thng nang va ac, nh v trc mo va sinh thiet vao ton thng thang ng hn.
loi. Cac bc khi au cho cac thu thuat qua da Neu ton thng nam xa thanh ngc va co nh
eu giong nhau va ky thuat at kim bang tay co c vu, oi khi co the thc hien viec nh v trc
sieu am hng dan cung vay. mo va choc hut nang vi hng doc thang ng
Phai c s ong y cua benh nhan trc khi hn t phan gia cua truc ln cua au do (xem
tien hanh thu thuat.85 Phai mo ta ro thu thuat va Hnh 23-33, B). ng vao nay co khoang cach ti
muc ch cua no cung cac bien chng co the xay ra ton thng ngan nhat, phau thuat vien thch ieu
(xem khung tren). Mac du co the chay mau chut t, nay hn. Viec s dung ky thuat th hai nay thng
ti nay chung toi cha gap khoi mau tu nao ang han che; nhn chung, nen chon nga vao minh hoa
ke khi lam sinh thiet loi bang kim ln. Benh nhan tren Hnh 23-33, A v an toan va cho phep thay
phai bieu lo a hieu nhng g se dien ra. c than kim trong suot thi gian lam thu thuat.
Tuyen nhu 781
Hnh 23-33. Hai ky thuat thc hien thu thuat can thiep bang tay di hng dan cua sieu am. A,
Phng phap chnh cho thu thuat nay la nga vao nam ngang hoac hi nghieng t au cua au do linear giup giam
nguy c bien chng. Ky thuat nay phu hp cho sinh thiet loi, sinh thiet choc hut kim nho, ton thng gan thanh ngc
hac vo manh cay hoac bat c khi nao can thay ro than va au kim trong khi ay kim vao ton thng. Muon the,
kim phai nam trong mat phang quet trai t phan gia au do nh minh hoa. B, nh v trc mo va choc hut mot so
nang co the dung nga vao thang ng trc tiep hn khi o ch thay mot om tang phan am tc ni chum song cat
ngang qua than kim. Khong thay than kim nhng khoang cach gia ni vao da en ton thng co the ngan hn va
c cac phau thuat vien a chuong hn. Tren ay, ton thng nam iem gia cua truc ln cua mat au do va co
the o khoang cach. Ch can chut kinh nghiem, co the uc lng kha chnh xac goc hng au kim. (Trch t
Mendelson EB, Tobin CE. US-guided interventions: fine-needle aspiration and large-core needle biopsy. RSNA
Categorical Course in Breast Imaging: 1995:139-149.)
au do linear 7,0 MHz hoac tan so cao hn phai nam trong mat phang quet, a nam trong mat
thch hp nhat cho thu thuat bang tay. Mot so au phang quet th bat c mot kim bnh thng nao
do co kem theo bo dan ng nhng chung toi cung thay c du to hay nho.
khong thay cac dung cu nay lam giam c s kho Co nhieu tuy chon cho nhom thc hien. Mot
khan cua thu thuat hoac lam tang them o chnh ngi cam au do thc hien thu thuat. Nhng
xac. ngi phu co the giup gi au do. Neu ngi phu
Nhng kho khan e thay c kim thuc ay quet, ngi chnh co ca hai ban tay e thc hien
viec phat trien cac au kim c phu, lam ro hoac thu thuat am kim.
lam xc e tang o phan am. Chung toi thay Mot trong nhng oi hoi quan trong nhat e
chung cung khong co li g. e thay c kim, no thanh cong la co nh ton thng ben di au do.
oi hoi th hai la at au do sao cho thay c sinh thiet.88 Hien tai sinh thiet loi c thc hien
hng vao cua kim so vi lo trnh nh trc cua vi sung lay co va kim 14-G. Vi mo vu co nhieu
chum song am. mo m va si tuyen, lay mo bang kim 14-G cho
thay thuan li hn cho phan tch mo hoc so vi lay
Ky thuat cua cac thu thuat chuyen biet mo bang kim 18 hay nho hn.89 Sinh thiet kim ln
Choc hut nang. Phai co nh vung nang bang con co the lam bang kim cat 14-G hay kim c hoc
tay nh o kim co the i xuyen qua thanh nang 11-G (Hnh 23-34). Chan khong giup em mau vao
thay v ay no lech khoi mat phang quet. Khi buong thu thap de dang hn.
au, nen dung kim nho. Neu chat cha trong nang Sinh thiet bang kim ln di hng dan cua
co o nht thap, co the dan thoat nhanh va hieu sieu am co cung li iem nh cac thu thuat co sieu
qua. Neu nang co bao x, dai, kim co the b lech am hng dan khac. Nhieu cach chon t the benh
i. Khi o, can dung kim cng va ln hn e co the nhan. T the nam nga hay nga-chech de chu
xuyen qua thanh day. Neu th lan au vi kim 24- hn so vi t the nam sap hoac ngoi nh khi chup
G khong thanh cong, th lan hai vi kim 18-G. nhu anh nh v ba chieu. Phng phap nh v ba
Cung co the s dung kim 18 en 19-G ngay t au chieu khong cho phep quan sat tc th lien tuc
e tranh choc hai lan. ng i cua kim va cung khong nhanh bang sieu
Neu nang rat ln, dung ong tiem 20 ml kem am ngay ca khi a ap dung ky thuat so hoa.
ong noi e dan thoat c hieu qua. oi vi nang Mot van e at ra la kha nang gieo rac te bao
nho hn, cac loai kim va ong tiem di da, sung ac tnh sau khi sinh thiet bang kim ln. Mot trng
choc hut va ong chan khong loai dung choc tnh hp nh the a c bao cao sau khi choc hut bang
mach eu hoat ong tot. kim ln mot carcinom nhay.90 S song cua te bao
Chung toi hut ngay khi ang quet, khong di trong lo trnh kim cha c biet ro, nhng khong
chuyen au do cho ti khi hoan tat thu thuat.Ghi thay co s phat tan benh cung nh di can trong sinh
lai hnh sieu am trc va ngay sau thu thuat, thiet phoi qua da va cac tang trong bung, von a
thng con lu kim tai cho. Sau choc hut, thc hien c thc hien t nhieu nam nay.
chup nhu anh the nghieng hoac chieu the nao cho Ky thuat tong quat cho sinh thiet loi di
phep thay s tng ong ve benh ly gia nhu anh hng dan cua sieu am c minh hoa (xem Hnh
va sieu am. 23-33, A). Dung khoang 2 en 5 ml lidocain 1%.
Lien quan ti hnh thai cua dch trong nang, Mot kenh lidocain hay nc muoi tao ra t da ti
nhieu bac s hnh anh va lam sang loai bo dch ton thng e bieu th goc vao cua kim 14-G va
vang hay thanh t va dch mau xanh la cay gi y lam cho kim 14-G hay kim ln hn i vao de hn v
bien oi x nang. Bat c dch mau hay dch nao oi khi co e khang. Co the pha bicarbonat vao
khac eu phai mang phan tch te bao. Neu chat hut dung dch lidocain e ngan nga cam giac bong rat
giong mu, ngoai khao sat te bao hoc phai khao sat khi gay te tai cho.91
vi sinh (cay hoac o nhay cam). Co the phai lu Co the tao mot kha nho tren da u e kim 14-
cac cathete dan lu ap xe neu con dch ong ang G i vao de ma khong ket da. Thong thng ch
ke sau khi choc hut khong tron ven. mot kha la u. Co the hng kim di hng dan
Sinh thiet bang kim loi ln. Sinh thiet kim cua sieu am i vao vung lay mau cua khoi u. Cung
ln a tr thanh mot thu thuat chan oan benh ly co he thong ong truc dung trong sinh thiet kim ln
vu quan trong trong vai nam gan ay. Ket qua te di hng dan cua sieu am.92
bao benh hoc Hoa ky thay oi, t le lay mau mo Vi viec nhn thay ro ng i, kim c
khong u len ti 25% trng hp trong mot so hng ve pha ton thng. Co the bop co sung sinh
nghien cu. V the, e lay mau mo khong qua thiet v tr cach quang vi ton thng tuy vao
phau thuat, viec sinh thiet bang kim ln ang c kch thc ton thng, v tr vung lay mau ( 0,4 cm
ap dung ngay cang nhieu.87 Ca sieu am va nhu anh t au kim), chieu dai vung lay mau t 1,7 en 1,9
nh v ba chieu a chng to o chnh xac trong cm va lc ay kim khi bop co sung ( 2,2 en 2,3 cm
viec hng dan at kim va moi cai eu co li vi kim vn dai c a chuong hien nay).93
iem. Cac nghien cu cho thay o tin cay cua sinh at tng mau vao lo co formol co nh 5%,
thiet bang kim ln co the thay the c phau thuat khong nhung au kim vao formol neu con dung
Tuyen nhu 783
Hnh 23-34. Sinh thiet loi bang kim ln. A, Khoi nghi ng (M) vi vien
tang phan am (mui ten cong) va ton thng ve tinh dang mau loi. B, e chan
oan mo hoc trc khi la chon phng phap ieu tr ung an, tien hanh sinh
thiet loi vi kim ln 14-G (ky thuat chan khong). C, Sau sinh thiet loi, nhu anh
the nghieng cho thay khoi vi t dai sau thu thuat va mot o tu kh nho (mui ten)
tai iem lay mau. Khong co khoi mau tu.
kim e lay them mau. Can xac nh so ng vao khoi ac mi xuat hien phai trai qua sinh thiet kim
lay mau e co c chan oan chnh xac bang ln hay phau thuat cat bo.
cach hoi chan vi nha giai phau benh. oi vi u, S thanh cong cua sinh thiet bang choc hut vi
thng thc hien 5 en 6 ng vao. oi vi voi kim nho (FNAB) tuy thuoc vao 6 yeu to sau ay:
hoa li ti, thc hien so lng ln hn.94 Sinh thiet loi 1. S quen thuoc vi hnh anh sieu am cua nhieu
trong trng hp voi hoa nho thng c thc ton thng vu
hien vi nhu anh nh v ba chieu, du mot so ong 2. Kinh nghiem s dung sieu am e hng dan
voi nho co the thay tren sieu am nhat la khi ong 3. Viec at kim chnh xac vao vung ngoai vi,
voi trong khoi u. trung tam hay vung nao khac nh mong muon
Sinh thiet bang choc hut vi kim nho. Neu 4. Ky thuat choc hut hieu qua e lay u te bao
khong lay c dch t khoi ma bieu hien co the la khong vay them mau
nang phuc tap, nen lam mot tieu ban vi chat lay 5. Chuan b tc th cac tieu ban tuy thuoc y thch
trong kim e anh gia te bao benh hoc. Neu khong cua nha te bao hoc (neu ho co mat tai cho, ho
u e khao sat hoac ly giai khong xac nh ro, mot co the cho biet viec lay mau u cha)
6. Kinh nghiem cua nha te bao hoc trong anh Ky thuat khac na la s dung thiet b kim ong
gia ton thng vu , ma toi thieu phai phu hp truc vi nong ngoai la kim 19-G at tai ra ton
vi hnh anh hoc trong khi lam thu thuat . thng, sau o mot kim nho hn c 21-G a
Bang mot trong hai ky thuat tiep can bang tay xuyen qua nong e lay mau.
mo ta tren, viec ay nhanh ti lui chut t vao ton FNAB phai c ngi lam sieu am hay ngi
thng c thc hien vi kim 21G en 23G va oc nhu anh co kinh nghiem thc hien cung nh
ong tiem di hng dan cua sieu am, s dung ap nha te bao benh hoc gioi se cho chan oan ac tnh
lc am. ong tac len xuong nhanh gon nhng tin cay, khong co dau hieu dng tnh gia. e
nhieu lan nay lam cho chat lieu trong u i vao tranh loi trong lay mau va tranh ket qua am tnh
trong kim. Neu co thay mau, nen cham dt thao tac gia, oi vi mot so ton thng x hoa, carcinoma
va bat au thc hien tieu ban. tieu thuy xam nhiem va cac bat thng trong vung
Cai tien ky thuat nay la dung mot sung hut. a a xa tr, tot nhat nen sinh thiet loi bang kim ln.
so cac sung dung ong tiem 10 ml, de s dung, cho nh v trc mo. Mot thu thuat rat quan
phep ngay ca cac ban tay nho nhat cung co the tao trong cung co the c sieu am hng dan la nh
ap lc am hieu qua e thu thap chat hut. v trc mo bang kim co day moc (Hnh 23-35).96
Mot phng phap khac la dung kim 23 en 25- Sieu am co nhieu li iem so vi nhu anh dung
G ma khong co ong tiem. Thao tac len xuong tam ep co ca so. Benh nhan thng nam nga-
nhanh nh tren se lam te bao vao kim qua tac dung chech hoac nga giong nh luc mo va nga vao cua
mao dan.95 Sau o mot syringe cha san vai ml sieu am thng la ni co khoang cach ngan nhat t
khong kh c gan vao kim e ay chat trong da ti ton thng, mot cach tiep can c cac phau
long kim len knh tieu ban a chuan b nh tren. thuat vien a chuong. Co the dung mot trong hai
cach a mo ta (xem Hnh 23-3).
Hnh 23-35. nh v trc mo di hng dan cua sieu

am. A, Dung phng phap kim i vao thang ng (xem Hnh 23-
33, B) ch thay mot phan cua day moc (mui ten) hien len trong
khoi u co ve ac tnh. B, X quang mau mo cho thay khoi u co b
gai vi au day moc chieu chong len vung ung th. C, Co the thc
hien sieu am mau cat e xac nh s hien dien cua khoi, M, ben
trong mo cat bo. Nhng phan am dang thang phat sinh t pha ay
cua bnh cha.
Tuyen nhu 785
Ch nh sieu am hng dan cho cac ton S kheo leo khi can thiep vu di hng dan
thng khong the tiep can c bang ky thuat nhu cua sieu am cho phep chuyen gia hnh anh hoc
anh vi tam ep co ca so, nh nhng ton thng uyen chuyen va linh ong hn khi la chon cac
nam vung uoi tuyen vu pha nach hay nam xa phng phap khong phau thuat thay the e chan
pha sau va bat c khoi nao va ton thng khac oan va x tr cac benh ly vu. Ket qua mong i
thay c tren sieu am. Benh nhan khong can phai la viec cai thien c tnh hieu qua va tnh kinh te
nam nga hay nam chech. Benh nhan co the ngoi cua viec cham soc benh nhan.84
hoac ng neu thay ro ton thng nhat va de tiep
can cac t the nay. Neu ton thng co gii han CHAN THNG VA CAC THAY OI SAU
ro, giam phan am va co the la nang khong ien PHAU THUAT
hnh th tot hn nen lay day moc khoi kim trc khi
at kim. Neu co dch trao ra, co the gan ong tiem Trong chan thng vu, khong the chup nhu anh v
vao va hut dch. mo vu b dap va au, sieu am co the phat hien cac
Khi a chac chan at kim ung cho, co the khoi tu dch phc tap vi cac mc o phan am
trien khai day moc trong mo. Nhu anh xac nh v khac nhau tuy vao mc o cap tnh cua vet thng.
tr cua kim trc khi moc day. Hnh dang cua cac vung xuat huyet co the tron hay
Hnh nhu anh phai c chu thch ay u, the bau duc nhng thng co b lm chm do mau lam
tren-di, the nghieng, cho thay v tr day moc va boc tach cac ban mo. Neu co nhu cau ve hnh anh
gi ti phau thuat vien. hoc, co the theo doi cac thay oi bang sieu am cho
oi vi tat ca cac ton thng khong s thay ti khi co the chup nhu anh ma khong gay kho chu
c nh v trc mo, can thiet phai co hnh anh nhieu cho benh nhan. Khi khoi mau tu tan dan th
cua mau. nh v bang nhu anh oi hoi hnh X co the phat trien cac vung seo va hoai t m.
quang cua mau. Vi sieu am, cac hnh anh cua Sieu am ac biet hu ch khi anh gia tuyen
mau ton thng co the ghi nhan bang nhu anh, sieu vu a phau thuat nang ngc. Nhu anh b han che
am hoac ca hai. Ngay ca khi ton thng khong thay va sieu am la bien phap thay the hu ch44,45 Ngoai
tren nhu anh, hnh X quang cua mau van hu ch. nhng bat thng cua chu mo, cac khiem khuyet,
Bang cach e ep nhieu hn va phong ai ln hn phan thuy, r va co that lien quan ti tui ghep eu
oi vi mot mau mo, oi khi co the thay bat co the chan oan c bang sieu am. V ngoai bao
thng ma trc o khong nhan ra tren nhu anh hay v vao mo vu va nach hien len di dang cac
trc phau thuat. Phai bao cao cac dau hieu cua phan am khong nh hnh, nhieu phan am, hoac
mau cho phau thuat vien tai phong mo trc khi hnh thai bao tuyet (Hnh 23-36).97,98 e chan
ong vet mo. oan v trong bao , MRI nhay cam hn sieu am99
Hnh 23-36. V tui ghep ngoai bao: hnh thai ac trng. O tu silicon t do khong nh
hnh (FS) nam trong mo ben ngoai vo bao (mui ten) cua tui ghep silicon mot long. Mac du phan
am cua silicon giam pha xa, silicon can tr viec khao sat cac cau truc nam sau.
Hnh 23-37. ieu tr bao ton vu: tu dch sau mo. A, 18 thang sau khi cat cho sng kem xa tr v
carcinoma ong tham nhiem, hnh nhu anh phong ai the tiep tuyen cho thay da day len (au mui ten) tai vet
mo (co day at tren da) va mot vung mat o mo mem hnh ellip tai v tr u a cat bo (mui ten). Thay c
ng t vet mo vao ti u (mui ten cong). B, Hnh sieu am oi chieu cho thay tu dch (C), vi b khong eu
(mui ten) do bien oi x hoa (mui ten). Da day lien quan ti xa tr cung thay c tren sieu am (au mui
ten). Nhng khoi tu nay bien mat trong vong mot hoac hai nam va seo thay the co bong lng sau (S). Thay
c lo trnh t vet mo en hoc u (mui ten cong).
Hnh 23-38. Nang dau va hoai t m sau mo vu. A, Nhu anh cho thay vung thau quang tron, gii
han ro (au mui ten) hnh thanh sau thu thuat. Nhng nang dau nay hap thu, ong voi va tr thanh nhng
vung x hoa va hoai t m. B, Hnh anh sieu am ien hnh cua mot nang dau, ay cha mot so chat can
trong long (au mui ten). Ton thng dang nang se co thanh khong eu kem bong lng sau mot khi hoai t
m va tao seo phat trien.
Tuyen nhu 787
carcinoma vu.44 Cac dau hieu lam sang va nhu anh

cua carcinoma tai phat co the giong nh cac bien
oi sau mo va sau xa tr, bao gom khoi u, phu, da
day va voi hoa.45 Hoc con lai sau khi lay khoi u
thng lap ay dch. Nhng khoi tu dch nay co the
tan het sau khoang thi gian t 6 en 18 thang va
sieu am c dung e khang nh khoi m thay
tren nhu anh hay s thay tren lam sang cha ay
dch va xac nh no giam dan theo thi gian (Hnh
23-37).44,45,101 Ve sau, vi s phat trien hoai t m
(Hnh 23-38) va cac bien oi sau phau thuat khac
nh seo, b cua khoi tu dch sau mo the tr nen
khong eu va co bong lng phat sinh t vung
nay.44,45 Khi a tao seo, viec phat hien mot khoi
ln hay nhieu not mi xuat hien vung seo, co the
ngh ti kha nang khoi u khu tru tai phat.
THAM KHAO
1. Adier DD, Wahl RL. New methods for imaging the breast:
techniques, findings and potential. AJR 1995; 164: 19 - 30.
2. Tabar L, Fagerberg CJC, Gad A et al. Reduction in mortality
from breast cancer after mass screening with mammography.
Lancet 1985; 1: 829 - 832.
3. Feig SA. Methods to identify benefit from mammographic
screening of women aged 40 - 49 years. Radiology 1996: 201: 309
- 316.
4. Kopans DB. Mammography screening and the controversy
concerning women aged 40 to 49. Radiol Clin North Am 1995; 33:
1273 - 1290.
5. Jackson VP. The current role of ultrasonography in breast
imaging. Radiol Clin North Am 1995; 33: 1161 - 1168.
6. Jackson VP. Role of US in breast imaging. Radiology 1990: 177:
305 - 311.
7. Monsces BS. E valuation of breast microcalcifications. Radiol
Clin North Am 1995; 33: 1109 - 1121.
8. Dempsey PJ. Breast sonography: historical perspective, clinical
applications and image interpretation. Ultrasound Q 1988; 6: 69 -
90.
9. Rubin E, Dempsey PJ, Pile NS et al. Needle - localization biopsy
of tlic breast: impact of a selective core needle biopsy program
Hnh 23-39. Carcinoma ong tuyen tham nhiem tai on yield. Radiology - 1995: 195: 627.
phat 5 nam sau khi cat vung sng kem xa tr. A,
Ch nh
Nhu anh the tiep tuyen cho thay vet mo c anh dau bang 10. Feig SA. The role of ultrasound in a breast imaging center. Semin
day, vung cat co seo va ong voi lanh tnh (mui ten cong), US CT MR 1989; 10: 90 - 105.
ong voi tai ni may (au mui ten) va mot mat o m gan
Trang thiet b
ni cat u. B, Sieu am bong m phat hien khoi giam phan am
11. Jackson VP. Kelly - Frv E. Rothschild PA et al. Automated breast
hnh dang khong eu (mui ten) nam gia cac tieu thuy m.
sonography using a 7. 5 MHz PVDF transducer: pre - liminary
Sinh thiet loi di hng dan cua sieu am xac nh u tai clinical evaluation. Radiology 1986; 159: 679 - 684.
phat. 12. Bassett LW, Kimme - Smith G. Breast sonography: technique,
equipment and normal anatomy. Semin US CT MR 1989; 10: 82 -
89.
du sieu am co gia tr tien oan am tnh cao oi vi 13. Stavros AT, Thickman D, Rapp CL et al. Solid breast nodules:
use of sonography to distinguish between benign and malignant
v tui ghep.100 lesions. Radiology 1995; 196: 123 - 134.
Cung vi nhu anh, sieu am oi khi cung c 14. Gosgrove DO, Bamber JG, Davey JB et al. Color Doppler signals
dung e anh gia v tr cat vung sng trong from breast tumors. Work in progress. Radiology - 1990: 176: 175.
15. Cosgrove DO, Kedar BP, Bamber JC et al. Breast diseases: color 37. Jackson VP. Sonography of malignant breast disease. Semin US
Doppler US in differential diagnosis. Radiology 1993; 189: 99. CT MR 1989; 10: 119 - 131.
16. McNicholas MMJ, Mercer PM, Miller JC et al. Color Doppler 38. Gole - Beuglet C, Soriano RZ, Kurtz AB et al. Ultrasound
sonography in the evaluation of palpable breast masses. AJR analysis of 104 primary breast carcinomas classified according to
1993; 161: 765. histopathologic type. Radiology 1983; 147: 191 - 196.
17. Minasian H, Bamber JC. A preliminary assessment of an 39. Cole - Beuglet C. Sonographic manifestation of malignant breast
ultrasonic Doppler method for the study of blood flow in human disease. Semin Ultrasound 1982; 3: 51 - 57.
breast cancer. Ultrasound Med Biol 1982; 8: 357. 40. Mendelson EB, Bohm - Velez M, Bhagwanani DC et al.
18. Schoenberger SG, Sutherland CM, Robinson AE. Breast neo - Sonographic spectrum of fibroadenomas: a guide to clinical
plasms: duplex sonographic imaging as an adjunct in diagnosis. management. Paper presented at the Radiological Society of
Radiology 1988; 168: 665 - 668. North America Annual Meeting. Chicago; 1988.
19. Kedar RP, Cosgrove D, McCready VR et al. Microbubble 41. Harper AP, Kelly - Fry E, Noe JS et al. Ultrasound in the
contrast agent for color Doppler US; effect on breast masses. evaluation of solid breast masses. Radiology 1983; 146: 731 -
Work in progress. Radiology 1996; 198: 679 - 686. 736.
42. Logan WW, Hoffman HY. Diabetic fibrous disease. Radiology
Ky thuat khao sat
1989: 172: 667 - 670.
20. Rubin E, Miller VE, Borland LL et al. Hand - held real - time
43. Tobin CE, Hendrix TM, Geyer SJ et al. Breast imaging case of
breast sonography. AJR 1985; 144: 623 - 627.
the day. Radiographics 1996; 16: 983 - 985.
21. Hilton SVW, Leopold GR, Olson LK et al. Real - time breast
44. Mendelson EB, Imaging the post - surgical breast. Semin US CT
sonography: application in 300 consecutive patients. AJR 1986;
MR 1989, 10: 154 - 170.
147: 479 - 486.
45. Mendelson EB. Evaluation of the postoperative breast. Radiol
Thu thap d lieu Clin North Am 1992; 30: 107 - 138.
22. ACR Standard for Performance of the Breast Ultrasound 46. Tavassoli FA. Pathology of the Breast. Norwalk, Conn. :
Examination. Reston, Va: American College of Radiology; 1995: Appleton and Eange; 1992: 399 - 403.
209 - 211. 47. Sickles EA. Management of lesions appearing probably benign at
Giai phau sieu am mammography. In: Radiological Diagnosis of Breast Diseases.
23. Kopans DB, Mever JE, Proppe KH. Double line of skin Berlin: Springer - Verlag; 1997: 168.
thickening on sonograms of the breast. Radiology 1981; 141: 485 48. Eanyi M. Differential Diagnosis of Microcalcifications. In:
- 487. Friedrich M, Sickles EA. Radiological Diagnosis of Breast
24. Spencer GM, Rubens DJ, Roach DJ. Hypoechoic fat: sonographic Diseases. Berlin: Springer - Verlag; 1997: 89 - 136.
pitfall. AJR 1995; 164: 1277. 49. Tavassoli FA. Pathology of the Breast. Norwalk, Conn. :
25. Sewell CW. Pathology of benign and malignant breast disorders. Appleton and Eange; 1992: 294 - 347.
Radiol Clin North Am 1995; 33: 1067 - 1080. 50. Mendelson EB, Tobin CE, Merritt CRB et al. Marginal analysis
26. Tobin CE, Hendrix TM, Geyer SJ et al. Breast imaging case of of breast masses with high resolution US (abstract). Radiology
the day. Radiographics 1996; 16: 1225 - 1226. 1994; 193(P): 177.
27. Rosen PP. Breast Pathology Philadelphia: Lippincott - Raven; 51. Howell A, Harris M. Infiltrating lobular carcinoma of the breast.
1997: 1 - 15. Br Med J 1985; 291: 1371.
28. Yang WT, Ahuja A, Tang A et al. Ultrasonographic 52. Dixon JM, Anderson TJ, Page DE et al. Infiltrating lobular
demonstration of normal axillary lymph nodes: a learning curve. carcinoma of the breast: incidence and consequence of bilateral
J Ultrasound Med 1995; 14: 823 - 827. disease. Br J Surg 1983; 70: 513 - 516.
29. Gordon PB, Gilks B. Sonographic appearance of normal 53. Meyer JE, Amin E, Eindfors KK et al. Medullary carcinoma of
intramammary lymph nodes. J Ultrasound Med 1988; 7: 545 - the breast: mammographic and sonographic appearance.
548. Radiology 1989; 170: 79 - 82.
30. Chan INV, Troupin RH, Yeh I - T. Solid axillary masses: 54. Feig SA, Shaber GS, Patchefsky AS et al. Tubular carcinoma of
attempts at sonographic differentiation of an axillary lymph node the breast. Radiology 1978; 129: 311 - 314.
from fibroadenoma. Breast Dis 1989; 2: 187 - 194. 55. Elson BC, Helvie MA, Frank FS et al. Tubular carcinoma of the
breast: mode of presentation, mammographic appearance, and
Phng cach anh gia u frequency of nodal metastases. AJR 1993; 161: 1173 - 1178.
31. Mendelson EB, Tobin CE, Merritt CRB et al. Marginal analysis 56. Fisher ER, Palekar AS, Kotwal N et al. A non - encapsulating
of breast masses with high resolution US. Radiology 1994; sclerosing lesion of the breast. Am J Clin Pathol 1979: 71: 239 -
193(P)(suppl): 77. 246.
32. Breast Imaging Reporting and Data System (BI - RADS). 57. Baker, RR. Unusual lesions and their management. Surg Clin
Reston, Va: American College of Radiology; 1993: 15. North Am 1990: 70: 963 - 975.
Nang 58. Page DE, Anderson . Diagnostic Histopathology of the Breast.
33. Moskowitz M. Predictive value of certain mammographic signs Edinburgh: Churchill Eivingstone; 1987: 186 - 187.
in screening for breast cancer. Cancer 1983: 51: 1007 - 1011; (ab) 59. Hughes LE, Mansel RE, Webster DJT et al. Benign Disorders
149: 888. and Diseases of the Breast. London: Bailliere Tindal; 1988: 59 -
34. Garra BS, Cespedes El, Ophir J et al. Elastography of breast 73.
lesions: initial clinical results. Radiology 1997; 202: 79 - 86. Solid 60. Rosen PP. Breast Pathology. Philadelphia: Lippincott - Raven;
and Mixed Masses. 1997: 335 - 353.
35. The American Cancer Society: Breast Cancer Facts and Figures 61. Tobin CE, Hendrix TM, Resnikoff LB et al. Breast imaging case
1996. Atlanta: American Cancer Society; 1996: 1. of the day. Radiographics 1996; 16: 720 - 722.
36. Fornage BD, Eorigan JG, Andry E. Fibroadenoma of the breast: 62. Mitnick JS, Vazquez MF, Harris MN et al. Invasive papillary
sonographic appearance. Radiology 1989: 172: 671. carcinoma of the breast: mammographic appearance. Radiology
1990: 177: 803 - 806.
Tuyen nhu 789
63. Renter K, D' Orsi CJ, Reale F. Intracystic carcinoma of the 84. Lindfors KK, Rosenquist CJ. Needle core biopsy guided with
breast: the role of ultrasonography. Radiology 1984; 153: 233 - mammography: a study of cost - effectiveness. Radiology 1994;
234. 190: 217 - 222.
64. Fechner RE, Mills SE. Breast Pathology Chicago: ASCP Press; 85. ACR Standard for the Performance of Ultrasound - Guided
1990: 30. Percutaneous Breast Interventional Procedures. Reston, Va:
65. Rosen PP. Breast Pathology - Philadelphia: Lippincott - Raven: American College of Radiology: 1996.
1997: 143 - 155. 86. Reading CC, Charboneau JW. Ultrasound - guided biopsy of the
66. Dupont WD, Page DL, Parl FF et al. Long - term risk of breast abdomen and pelvis. In: Rumack CM, Wilson Sr, Charboneau
cancer in women with fibroadenoma. N Eng J Med 1994: 331: 10 JW, eds. Diagnostic Ultrasound. St. Louis: Mosby - Year Book;
- 15. 1991: 429.
67. Jackson VP, Rothschild PA, Kreipke DL et al. The spectrum of 87. Fajardo LL, Jackson VP, Hunter TB. Interventional procedures in
sonographic findings of fibroadenoma of the breast. Invest Radiol diseases of the breast: needle biopsy, pneumocystography, and
1986; 21: 31 - 40. galactography. AJR 1992; 158: 1231.
68. Mendelson EB, Bohm - Velez M, Bhagwanani DG et al. 88. Parker SH, Burbank F, Jackman RJ et al. Percutaneous largecore
Sonographic spectrum of fibroadenomas: a guide to clinical breast biopsy: a multi - institutional study. Radiology 1994: 193:
management. Paper presented at the Radiological Society of 359 - 364.
North America Annual Meeting, Chicago; 1988. 89. Dowlatshahi K, Yaremko ML, Kluskens LF et al. Nonpalpable
69. Sickles EA. Management of probably benign breast lesions. breast lesions: findings of stereotaxic needle-core biopsy and fine
Radiol Clin North Am 1995; 33: 1123 - 1130. - needle aspiration cytology. Radiology 1991: 181: 745 - 750.
70. Jackson VP. Benign breast lesions. In: Bassett LW, Jackson VP, 90. Harter LP, Curtis JS, Ponto G et al. Malignant seeding of the
Jahan R, Fu YS, Gold RH, ed. Diagnosis of Diseases of the needle track during stereotaxic core needle breast biopsy.
Breast. Philadelphia: WB Saunders Co; 1997: 429 - 435. Radiology 1992: 185: 713 - 714.
71. Haagensen CD. Diseases of the Breast, 3rd ed. Philadelphia: WB 91. Parker SH, Lovin JD, Jobe WE et al. Stereotactic breast biopsy
Saunders Co; 1986: 267 - 312. with a biopsy gun. Radiology 1990; 176: 741 - 747.
72. Mendelson EB, Bohm - Velez M, Lamas C et al. Focal breast 92. Kaplan SS, Racenstein MJ, Wong WS et al. US - guided core
fibrosis: mimic of breast carcinoma. Paper presented at the biopsy of the breast with a coaxial system. Radiology 1995: 194:
American Roentgen Ray Society Annual Meeting, New Orleans; 573.
1989. 93. Hendrick RE, Parker SH. Stereotactic imaging. In: Syllabus: a
73. Adler DD. Ultrasound of benign breast conditions. Semin US CT categorical course in physics: technical aspects of breast imaging.
MR 1989: 10: 106 - 118. Oak Brook, 111: Radiological Society of North America; 1992:
74. Logan WW, Hoffman NY. Diabetic fibrous disease. Radiology 233 - 243.
1989; 172; 667 - 670. 94. Liberman L, Dershaw DD, Rosen PP et al. Stereotaxic 14 -
75. Rosen PP. Breast Pathology. Philadelphia: Lippincott - Raven; gauge breast biopsy: how many core biopsy specimens are
1997: 676 - 679. needed? Radiology 1994: 192: 793 - 795.
76. Adier DD, Jeffries DO, Helvie MA. Sonographic features of 95. Fornage BD. Interventional ultrasound of the breast. In:
breast hamartomas. J Ultrasound Med 1990; 9: 85 - 90. McGahan JP, ed. Interventional Ultrasound. Baltimore: Williams
77. Rosen PP. Breast Pathology Philadelphia: Lippincott - Raven; & Wilkins; 1990: 71.
1997: 67 - 75. 96. D' Orsi CJ, Mendelson EB. Interventional breast
78. Jackson VP. Benign breast lesions. In: Bassett LW, Jackson VP, ultrasonography. Semin US CT MR 1989; 10: 132.
Jahan R, Fu YS, Gold RH, eds. Diagnosis of Diseases of the Chan thng va bien oi sau phau thuat
Breast. Philadelphia: WB Saunders Co; 1997: 402. 97. Levine RA, Collins TL. Definitive diagnosis of breast implant
79. Gomez A, Mata JM, Donoso L et al. Galactocele: three rupture by ultrasonography. Plast Reconst Surgery 1991; 87: 1126
distinctive radiographic appearances. Radiology 1986: 158: 43 - - 1128.
44. 98. Harris KM, Ganott MA, Shestak KC et al. Silicone implant
80. Bland KI. Inflammatory, infectious, and metabolic disorders of rupture: detection with US. Radiology 1993: 187: 761 - 768.
the mamma. In: Bland KI, Copeland EM, eds. The Breast: 99. Gorczyca DP, DeBruhl ND, Ahn CY. Silicone breast implant
Comprehensive Management of Benign and Malignant Diseases. ruptures in an animal model: comparison of mammography, MR
Philadelphia: WB Saunders Co; 1991: 87 - 112. imaging, US, and CT. Radiology 1994: 190: 227 - 232.
81. Vega A, Garijo F. Radial scar and tubular carcinoma: 100. Venta LA, Salomon SG, Filsak ME et al. Sonographic signs of
mammographic and sonographic findings. ACTA Radiol 1993; 34: breast implant rupture. AJR 1996: 166: 1413 - 1419.
43 - 47.
101. Balu - Maestro C, Bruneton J - N, Geoffray A. Ultrasonographic
82. Rosen PP. Breast Pathology. Philadelphia: Lippincott - Raven; post - treatment follow - up of breast cancer patients. J US Med
1997: 420 - 424. 1991: 10: 1 - 8.
Thu thuat can thiep
83. Evans WP. Breast Masses. Radiol Clin North Am 1995: 33: 1085
- 1108.
C H N G 2 4
Bu

Timothy J. Dambro, M.D.
Rhonda R. Stewart, M.D.
Barbara A. Carroll, M.D.
D A N B A I lam sang trong anh gia benh ly bu; sieu am bu

c chng minh la phng tien anh gia chnh
KY THUAT HNH ANH xac nhieu benh ly cua bu. S tien bo trong hnh
GIAI PHAU HOC anh ong thi gian thc vi o phan giai cao (high
KHOI U CUA BU resolution real-time) va sieu am mau cho thay s
Cac u ac tnh gia tang ng dung sieu am bu.
Cac u te bao mam (germ cell tumors))
U mo em (stromal tumors)
KY THUAT HNH ANH
U an (occult) nguyen phat
Di can tinh hoan
Di can, benh bach cau (leukemia) va
Tham kham bu va hoi benh s la can thiet trc
lymphoma khi sieu am. Khao sat tiep xuc trc tiep bu thng
Cac di can khac c ap dung nhng cung co the dung tui nc.
Cac ton thng lanh tnh trong tinh hoan Bat c chat dan am nao cung co the s dung.
Nang Benh nhan nam t the nga. Bu c nang len
Gian ong cua li tinh hoan (rete testis) vi mot khan at tren hai ui va dng vat e len
Loan san dang nang bung benh nhan va c che lai. Mot cach khac la
Nang dang bieu b (epidermoid) bu c nang bang tay cua ngi lam sieu am.
Ap xe Yeu cau benh nhan ch ra v tr au va not co the
Nhoi mau s c trong bu. Ngi khao sat sieu am co the
Benh sarcoid (Sarcoidosis) tham kham trong qua trnh lam sieu am. Thng
Manh sot tuyen thng than (Adrenal dung au do 7,5 en 10 MHz v cho hnh anh cau
rests) truc cac tinh hoan vi o phan giai cao. Neu can
Voi hoa vung bu khao sat vung sau hn, co the dung au do 5 MHz
Benh ly ngoai tinh hoan hoac vi nhng tinh hoan sng to, co the dung 3.5
Tran dch, tran mau va tran mu tinh mac
MHz, khao sat tren hai mat cat ngang va doc. Neu
Gian tnh mach thng tinh (varicocele)
co the, khao sat hai tinh hoan tren mot mat cat
Thoat v bu
ngang e so sanh. Cac mat cat bo sung gom cat
Cac u
nghieng hoac mat phang tran vi benh nhan nam
Cac ton thng mao tinh
BENH LY CAP CUA BU nghieng hoac dung nghiem phap Valsalva khi can
Xoan thiet. Co the dung sieu am mau hoac mode nang
Viem mao tinh va viem tinh hoan-mao tinh lng e anh gia tuan hoan trong tinh hoan bnh
CHA
CacNphng
THNG tien hnh anh ho tr tham kham thng hoac benh ly.
TINH HOAN AN (CRYPTORCHIDISM)
GIAI PHAU
CAC CH NH HIEN NAY
CHO SIEU AM BU * Tinh hoan ngi trng thanh thng co dang bau
duc, kch thc 3 en 5cm dai, 2 en 4cm rong va
anh gia v tr va ac tnh cua cac khoi u bu
3cm ng knh trc sau. Trong lng trong
Phat hien u an nguyen phat benh nhan co benh ly
khoang 12,5 en 19 g. Kch thc va trong lng
di can a biet
Theo doi benh nhan co soi li ti tinh hoan tinh hoan giam theo tuoi.2,8,9 Tinh hoan c bao
Theo doi benh nhan co tien s u tan sinh tinh hoan, quanh bang vo bao si day trang, tunica albuginea.
leukemia hoac lymphoma Nhieu vach ngan mong (septula) moc ra t lp
anh gia benh ly ngoai tinh hoan trong cung cua tunica albuginea va hoi tu pha
anh gia benh ly bu cap sau tao thanh trung that tinh hoan (mediastinum
anh gia chan thng bu testis) (Hnh 24-1). Trung that tinh hoan tao s
nh v cac tinh hoan khong xuong nang cho cac ong va mach mau ra vao tinh
Phat hien gian tnh mach thng tinh benh nhan
hoan. Khi cac vach chay hng ra sau t lp
nam vo sinh
albuginea, chung tao ra 250 en 400 thuy dang mui
anh gia thieu mau tinh hoan bang sieu am Doppler
mau va Doppler nang lng
nhon cha cac tieu ong sinh tinh, gom khoang 840
ong tren mot tinh hoan. Do cac ong chay hng
* Tham khao 1-7 tam, chung ket hp tao 20 en 30 ong ln hn, goi
la ong thang (tubuli recti). Cac ong nay i vao
trung that tinh hoan, tao mang cac kenh ben trong
Hnh 24-1. Giai phau bnh thng trong bu

Bu 793
mo em tinh hoan goi la li tinh hoan (rete testi). gan long leo vao cc di tinh hoan qua cac mo
Li nay tan cung bang 10 en 15 ong ly tam dang xoang. Ong mao tinh tao goc nhon tai mat
ngang phan tren cua trung that tinh hoan, mang di cua uoi mao tinh va chay hng len ti
tinh dch t tinh hoan en mao tinh. thng tinh theo mat trong cua mao tinh. Mau phu
Ve mat sieu am, tinh hoan bnh thng co (appendix) mao tinh, phan con lai cua ong Muller,
cau truc phan am dang hat ong nhat, bao gom la mot cau truc nho bau duc nam pha di au
phan am mc trung bnh phan bo ong dang, giong mao tinh. Mau phu mao tinh la bieu hien cua mot
nh cau truc sieu am cua tuyen giap. Trung that ong ly tam tach ra va la mot cuong nho tach ra
tinh hoan oi khi co hnh anh mot dai thang tang khoi mao tinh, oi khi co cap. Hiem khi thay co
am hng tren xuong di ben trong tinh hoan cac mau phu khac hoac bat thng khac nh mach
(Hnh 24-2). Hnh anh nay rat thay tuy theo lng lac v .10
mo si va mo m hien dien. Thng thay ro nhat Ve sieu am, mao tinh thng ang am hoac
sau tuoi 15 va trc tuoi 60.9 Bnh thng, tunica hi tang phan am so vi tinh hoan, va cau truc tho
albuginea (bao trang) khong thay thanh mot cau hn. au mao tinh (globus major) thng khoang
truc rieng biet. Cac vach ngan (septula) cua tinh 10 en 12 mm ng knh va nam me ngoai cc
hoan co the thay di dang cau truc thang tang tren tinh hoan (Hnh 24-4). Than mao tinh co
hoac giam phan am (Hnh 24-2). Li tinh hoan co khuynh hng ang am hoac giam am nhe so vi
the thay nh vung dang nang giam phan am hoac au mao tinh va tinh hoan; kch thc bnh thng
nhieu vach ngan nam ke can au mao tinh. di 4 mm, trung bnh 1 en 2 mm. uoi, mau
Mao tinh co cau truc cong dai khoang 6 en 7 phu mao tinh, mau phu tinh hoan thng nhan ra
cm nam me sau-ngoai cua tinh hoan. No bao gom
au, than va uoi. au mao tinh la phan phnh ln
(globus major) nam gan cc tren tinh hoan va la
phan ln nhat cua mao tinh. No tao t 10 en 15
ong ly tam t li tinh hoan hp lai vi nhau tao
nen mot ong cuon duy nha goi la ong mao tinh
(ductus epididymis). Ong nay tao nen phan than
va phan ln uoi mao tinh. No dai khoang 600 cm
va theo mot lo trnh xoan cuon rat nhieu t au
en uoi. Than mao tinh nam ke b sau ngoai cua
tinh hoan. Phan uoi tc phnh nho (globus minor)
Hnh 24-3. Dai tinh hoan bnh thng. A, Khao sat

Hnh 24-2. Trung that tinh hoan bnh thng. Khao cat ngang tinh hoan cho thay dai thang phan am kem trong
sat doc cho thay trung that tinh hoan (mui ten), co hnh anh tinh hoan. B, Doppler mau cho thay ban chat mach mau cua
mo si m phan am quanh cau truc mach mau phan am trong. dai nay.
c tren sieu am khi co tran dch tinh mac. Dang pho o van toc ong mach trong tinh
Hieu biet ve cung cap mau ong mach cho tinh hoan hoac vo bao bnh thng cho thay thanh
hoan la quan trong e ly giai sieu am Doppler mau phan tam trng hng ti suot chu ky tim, phan
tinh hoan. Tinh hoan c cung cap mau chnh anh khang lc mach mau thap tinh hoan (Hnh
t ong mach tinh quan, ong mach c bu 24-5).3 Dang song ong mach tren tinh hoan rat
(thng tinh ngoai) va ong mach tinh hoan. thay oi hnh dang. Hai dang chnh cua song ong
ong mach tinh quan bat nguon t ong mach mach la: dang khang lc thap nh ong mach vo
bang quang di va chay en uoi mao tinh, tai o bao hoac trong tinh hoan va dang khang lc cao
no chia nhanh va tao thanh li mao mach. ong vi nh tam thu hep, ro net vi dong tam trng
mach c bu bat nguon t ong mach ha v, chay thap hoac bang khong (Hnh 24-6).3 Ngi ta tin
doc theo phan con lai cua cac cau truc thng tinh rang dang song khang lc cao phan anh tnh trang
qua vong ben, tiep tuc ti be mat cua tunica khang lc cao cua mo ngoai tinh hoan. ong mach
vaginalis, thong noi vi mao mach tinh hoan va tinh quan va ong mach c bu trong thng tinh
ong mach tinh quan. ong mach tinh hoan thng chu yeu cung cap mau cho mao tinh va mo ngoai
bat nguon t mat trc cua ong mach chu bung tinh hoan nhng cung cung cap mau cho tinh hoan
ngay di goc cac ong mach than. ong mach thong qua thong noi vi ong mach tinh hoan.
nay thng chay qua ong ben cung vi thng tinh Dai phan am kem trong tinh hoan c mo
ti phan sau tren cua tinh hoan. Khi ti tinh hoan, ta trong 10% tinh hoan bnh thng (xem Hnh 24-
ong mach tinh hoan phan nhanh va xuyen qua 3).11 Dai nay co b ro, thng thay mot phan ba
tunica albuginea (lp vo bao trang) va tao mang gia tinh hoan, gan vuong goc vi trung that tren
tren be mat tinh hoan trong mot lp c goi la lp mat cat doc, o khoang tren 3 mm ng knh va 3
mach (tunica vasculosa). Cac nhanh hng tam cm chieu dai. Sieu am Doppler pho cua dai nay
phat sinh t cac ong mach vo bao nay; cac nhanh cho thay dang song khang lc thap, ac trng cho
nay chay doc theo cac vach ngan hng vao trung mach mau cua tinh hoan bnh thng trong 50%
that. T trung that, cac nhanh nay tao nen cac trng hp. Song tnh mach khong ghi nhan vung
nhanh quat ngc chay ly tam ben trong nhu mo
tinh hoan ni o chung lai chia thanh cac tieu ong
mach va mao mach.7 Trong khoang phan na cac
tinh hoan bnh thng, ong mach xuyen trung that
cung cap mau cho tinh hoan, chay xuyen qua trung
that va chay hng ti ngoai bien cua tinh hoan.
Cac ong mach nay co the mot hoac hai ben, mot
hoac nhieu ong mach va thng thay di dang
mot dai giam phan am nam gia tinh hoan.
Hnh 24-4. au mao tinh bnh thng. Khao sat doc Hnh 24-5. Doppler mau va Doppler pho bnh
bu cho thay au mao tinh (mui ten) nam tren tinh hoan, T. thng cua ong mach tinh hoan. Dang song ac
Co lng dch nho gia cac lp tinh mach (au mui ten). trng khang lc thap vi dong chay tam trng ln (mui ten).
Bu 795
nay nhng van c cho la co, tao them o day quanh tinh hoan. Ch mat sau tinh hoan, ni bam
cua dai phan am kem nay. cua tinh hoan va mao tinh th khong lien tuc vi
Thng tinh bao gom ong dan tinh, ong mach tunica vaginalis. Lp trong hoac lp tang cua
c bu, ong mach tinh quan va ong mach tinh tunica vaginalis phu tinh hoan, mao tinh va phan
hoan, am roi tnh mach dang tua cuon, mach di cua thng tinh. Lp ngoai hoac lp thanh cua
bach huyet va than kinh cua tinh hoan. Ve mat tinh mac (tunica vaginalis) lot thanh trong cua bu
sieu am, thng tinh nam ngay di da va kho phan va dnh vao can phu bu. Mot lng nho dch
biet vi mo mem lan can trong ong ben.12 Thng thng thay nam gia hai lp nay nhat la trong cac
tinh co the thay trong bu khi co tran dch tinh mac vung cc va gia tinh hoan va mao tinh.
hoac dung Doppler mau khao sat. Cac lp bao phu bu thng khong tach biet
Dartos, lp si c nam ngay di da bu, lien c tren sieu am va thay nh la mot ng tang
tuc vi vach bu, chia bu thanh hai buong rieng am duy nhat. Neu hien mot loai dch nao o trong
biet. Thanh cua moi buong tao bi s ket hp ba thanh cua bu, co the nhan ra tunica vaginalis nh
lp can. mot cau truc rieng biet.2
Tunica vaginalis (tinh mac) la khoang gia
cac lp can cua bu va tunica albuginea cua tinh CAC KHOI U CUA BU
hoan. Trong qua trnh phat trien bao thai, lp
tunica vaginalis phat sinh t, mot tui phnh cua Sieu am bu co the xac nh u bu vi o nhay gan
phuc mac thai nhi i kem tinh hoan khi i xuong 100%. Sieu am ong mot vai tro quan trong trong
bu. Phan tren cua ong tinh mac trai t lo ben anh gia khoi u bu v tnh chnh xac 98% en
trong ti cc tren tinh hoan, thng b bt. Phan 100% trong phan biet benh ly trong va ngoai tinh
di, tunica vaginalis con gi dang tui kn xep nep hoan.5,14 S khac biet nay rat quan trong trong x
tr cho benh nhan v hau het u ngoai tinh hoan eu
lanh tinh, ngc lai hau het u trong tinh hoan la ac
tnh. Thc te, tat ca u trong tinh hoan c xem la
u ac tnh en khi co chng minh ngc lai.2
Hau het cac u tan sinh ac tnh cua tinh hoan co
phan am kem hn nhu mo tinh hoan bnh thng;
tuy nhien, xuat huyet, hoai t, voi hoa hoac thay
oi mo m co the tao s tang am trong cac u nay.
Cac u sinh am ong nhat thng la dien tien lanh
tnh do nhiem trung hoac bat thng mach mau.
Tuy nhien, ngay ca cac ton thng sinh am cung
cung phai c xem co nhieu kha nang ac tnh v
cac dien tien lanh tnh co phan am giam hoac tang,
co hnh anh khong ac hieu.
U tinh hoan chiem 1% en 2% tat ca cac u ac
tnh nam gii va la nguyen nhan gay t vong
ng hang th nam nam gii co tuoi t 15 ti
34.15 Khoang 65% en 94% benh nhan co u tinh
hoan thng bieu hien bang khoi u mot ben khong
au hoac tinh hoan ln toan bo va khoang 4% en
14% co trieu chng cua di can.2,16,17 90% en 95%
cac u tinh hoan nguyen phat co nguon goc te bao
mam va thng co o ac tnh cao.18 Ch 60% u te
Hnh 24-6. Dang song Dopler ong mach ngoai bao mam cua tinh hoan co mot dang mo hoc duy
tinh hoan bnh thng. ong mach c bu va ong nhat va phan con lai cha hai dang mo hoc hoac
mach tinh quan cua thng tinh cho thay dang song khang lc
cao ma khong kem dong chay tam trng ro (mui ten).
hn na. Cac u mo em sinh duc t te bao Sertoli
hoac te bao Leydig chiem 3% en 6% va phan ln hoan khac. Mot u te bao mam nguyen phat th hai
cac u tan sinh trung mo nay lanh tnh (xem khung). co the xay ra cung luc hoac khac luc trong 1% en
2,5% benh nhan ang co seminoma.
Cac u ac tnh Seminoma la loai u thng gap nhat trong tinh
Cac u te bao mam. U tinh (seminoma) thuan hoan lac cho. 8% en 30% benh nhan mang
nhat la loai u tinh hoan ngi ln ch mang mot seminoma co benh s tinh hoan khong xuong.17,20,21
dang te bao duy nhat, chiem 40% en 50% u tan Nguy c phat trien seminoma gia tang oi vi tinh
sinh te bao mam. Loai hon hp chiem 30%. hoan khog xuong ngay ca sau phau thuat em tinh
Seminoma xay ra vi nhom ngi hi ln tuoi khi hoan xuong (orchiopexy). Cung co nguy c cao
so sanh vi cac loai u khac, thng co xuat o nh phat trien ac tnh trong tinh hoan oi ben nam v
nam tuoi 40 en 50.2.13.19-21 Seminoma hiem khi tr bnh thng; do o sieu am c dung e tam
xay ra trc tuoi day th. Seminoma thng t ac soat u an trong tinh hoan con lai.
tnh hn so vi cac u tinh hoan khac va thng Ve ai the, seminoma la khoi u ac, chac, tron
nam gon trong tunica albuginea; ch 25% co di can hoac bau duc, chac va co kch thc thay oi t
tai thi iem chan oan. Nh tnh chat nhay phong not nho trong mot tinh hoa co kch thc bnh
xa va hoa tr cua u nguyen phat cung nh di can, thng cho ti mot khoi ln lam ph ai tinh hoan
seminoma co tien lng tot nhat trong cac u tinh toan bo.15 Tnh chat sieu am cua seminoma thuan
nhat tng ng vi hnh thai ong nhat tren ai
the (Hnh 24-7). Chung bao gom phan am kem
PHAN LOAI BENH HOC U TINH HOAN ong nhat, khong co voi hoa hoac nang.22 Cac u
nay co b lang hoac khong ro net nhng rat giam
U te bao mam phan am so vi nhu mo tinh hoan bnh thng.
U co mot loai mo hoc Carcinoma te bao phoi la u tan sinh te bao
Seminoma mam thng gap th hai. No thng xay ra kem
Kinh ien vi cac thanh phan te bao mam tan sinh khac, ac
Dang nang tinh dch biet u tui noan hoang (yolk sac tumor) va u quai
Carcinoma te bao phoi (embryonal cell carcinoma) (teratoma). U nay chiem 20% en 25% tat ca benh
Loai ngi ln
ly te bao mam ac tnh nguyen phat. Chung thng
Loai tre em
xay ra nhom tre tuoi so vi seminoma vi nh la
U xoang noi b
Teratoma thap nien th hai va ba. Hiem khi xay ra trc tuoi
Trng thanh day th hoac sau 50. Cac benh ly ac tnh nay
Khong trng thanh thng nho nhng co the thay the mot phan hoac
Chuyen ac
Choriocarcinoma
U co hn mot loai mo hoc
Teratoma va carcinoma te bao phoi
(teratocarinoma)
Choriocarcinoma va bat c loai nao khac
Cac ket hp khac
Cac u cua mo em sinh duc (gonadal stroma)

U te bao Leydig
U te bao Sertoli, u hat, u te bao Theca
Cac u mo em sinh duc nguyen phat
Phoi hp cac loai tren
Chnh sa t Mostoki FK, Price EB Jr. Tumors of the male genital

systems. Trong: Atlas of Tumor Pathology. Fascile 8, 2nd series.
Washington, DC: Vien Benh hoc Quan oi; 1973.
Hnh 24-7. Seminoma. Khoi u trong tinh hoan b ro, phan
am kem u the (dau thap); phan am kem hn ro ret so vi mo
tinh hoan bnh thng xung quanh, T.
Bu 797
toan bo tinh hoan ma khong lam tang kch thc cha cac thanh phan khong trng thanh nhng di
tinh hoan ro ret. Du kch thc nho, chung co can rat hiem.20 Sau tuoi day th, teratoma thng
khuynh hng ac tnh hn seminoma, thng xam cha cac thanh phan trng thanh va cha trng
lan vao lp tunica albuginea lam bien dang ng thanh xen lan vi cac loai te bao mam khac.
b tinh hoan (Hnh 24-8). Chung thng tao di can Teratoma ngi trng thanh thng ac tnh.
tang.2,21 The tre em, u xoang noi b hoac u tui Ve sieu am, teratoma thng xac nh ro,
noan hoang la nhng loai u thng gap tre chiem khong ong nhat, cha cac vung dang nang hoac
60% ung th tinh hoan trong nhom tuoi nay, thng ac vi kch thc khac nhau. Thng gap cac
xay ra trc hai tuoi. 95% tre co mc o vung phan am day tao bong lng, do qua trnh voi
alphafetoprotein gia tang. Ca carcinoma te bao hoa khu tru, sun, xng cha trng thanh, x hoa
phoi lan u xoang noi b eu t nhay vi xa tr va va seo khong voi hoa (Hnh 24-9).22
hoa tr so vi seminoma va t le song 5 nam la 25% Choriocarcinoma la loai u te bao mam hiem
en 35%. gap nhat, ch chiem khoang 1% en 3% u tinh hoan
Tnh chat sieu am cua carcinoma te bao phoi nguyen phat ac tnh.21 U nay hiem khi xay ra di
thng tng ng vi mo hoc. U thng khong dang thuan nhat; ch ghi nhan 18 trng hp trong
ong nhat, b khong ro so vi seminoma. U co the tong so hn 6000 ca u tinh hoan tai Vien Benh hoc
xam lan tunica vaginalis, lam bien dang b ngoai cua Quan lc (AFIP).23 Khoang 23% cac loai u
tinh hoan. Cac vung dang nang hien dien trong hon hp cha thanh phan choriocarcinoma.20 Xuat
mot phan ba so u13 va thng t gap cac o tang am o nh la tuoi 2 en 30. Cac u nay ac tnh cao va
co kem hoac khong kem bong lng. di can sm qua ng mau va bach huyet. Benh
Teratoma chiem khoang 5% en 10% u tan nhan thng co trieu chng do di can xuat huyet,
sinh nguyen phat cua tinh hoan.21 Theo To chc Y chay mau mui, oi ra mau va cac trieu chng than
te The gii, u nay c xep loai da tren s hien
cac thanh phan t cac lp te bao mam khac nhau
(noi b, trung b va ngoai b). Theo phan loai nay
co ba loai teratoma: loai trng thanh, khong
trng thanh va loai chuyen ac.17 Mot phan ba cac
teratoma di can va thng theo ng bach huyet
trong vong 5 nam.2,21 T le song 5 nam c bao
cao la 70%. Tuoi thng gap la tre s sinh, tre nho
va 30 en 40. tre s sinh va tre nho, teratoma la
u tinh hoan thng gap th hai va la loai u trng
thanh, biet hoa tot va lanh tnh. Mot so trng hp
Hnh 24-9. Teratoma ac tnh. Khao sat cat ngang tinh

Hnh 24-8. Carcinoma te bao phoi. U b khong ro, xam hoan thay teratoma ac tnh ln chiem gan het tinh hoan.
lan, E, qua cac lp cua tinh mac (mui ten). Lng t dch tinh Thanh phan nang, C ,va phan ac kem cac not nho tang am
mac. (mui ten) do cac not voi hoa nho. T, Phan tinh hoan bnh
thng con lai.
xay ra nam gii co tinh hoan an, lo tieu thap va

c quan sinh duc n ben trong th phat.20
Phan ln u mo em la u te bao Leydig, chiem
khoang 1% en 3% u tinh hoan va thng xay ra
tuoi 20 en 50.19,20,24 Benh nhan hau nh co tinh
hoan to khong au hoac s c khoi u. Khoang
15% benh nhan co to vu do tang tiet androgen,
estrogen hoac ca hai. Bat lc, giam kha nang tnh
duc, hoac nam hoa sm thanh nien. U hai ben
trong 3% cac trng hp; 10% en15% co xam lan
tai thi iem chan oan. Xuat huyet hoac hoai t
khu tru gap trong 25% cac trng hp.19,24 Cac u
nay thng nho, dang ac va giam phan am tren
sieu am (Hnh 24-11). Cac vung nang do xuat
huyet hoac hoai t oi khi thay trong cac ton
Hnh 24-10. Choriocarcinoma. Khao sat doc thay tinh
hoan tham nhiem lan toa bi chorio-carinoma(mui ten). Co thng ln.
cac vung ln dang nang do hoai t (mui ten) va cac vung Khoi u an nguyen phat. Sieu am ong vai tro
tang am tng ng vi xuat huyet va voi hoa (mui ten m). quan trong vi benh nhan tham kham lam sang
bnh thng nhng co di can trung that, sau phuc
kinh trung ng. Thng gap to vu nam gii do mac hoac tren on do carcinoma tinh hoan di
gia tang lng hormon hng duc (gonadotropin) can.26-28 Viec phat hien u an nguyen phat co tam
trong mau t te bao nuoi.17 Co the co di can ma quan trong trong quan ly benh nhan v neu khong
khong co chng c cua choriocarcinoma trong tinh lay i, di can se tiep dien. Sieu am co the phat
hoan. Sieu am cho thay khoi vi phan am hon hp hien cac u tan sinh tinh hoan khong s thay. U
do cha vung xuat huyet, hoai t va voi hoa. nguyen phat co the thoai trien thanh vet seo x
U te bao mam dang hon hp cha cac thanh tang phan am va co the voi hoa du benh ly di can
phan te bao mam tan sinh khac nhau vi nhieu xa lan rong. Co ly thuyet cho rang s thoai trien
cach ket hp khac nhau. Chung la loai u ac tnh nay do toc o chuyen hoa cao cua u va khong cung
nguyen phat thng gap th hai sau seminoma, ng u mau nuoi u. Thong thng, co the nhan ra
chiem 40% tat ca u te bao mam. Chung thng cac te bao u khong con song tren mo hoc trong cac
xay ra tuoi giong nh u tinh hoan khac khong trng hp nay.15,16 Tinh hoan b benh thng co
phai seminoma. Loai ket hp u quai va carcinoma kch thc bnh thng hoac nho. Dau hieu sieu
te bao phoi la loai u te bao mam hon hp thng am vi o phan am day co hoac khong co bong lng
gap nhat, trc ay goi la teratocarcinoma. No thng khong chuyen biet cho u bung phat
thng cha va thanh phan ac lan thanh phan nhng rat gi y cho chan oan trong tnh huong u
dang nang vi hnh anh sieu am tng t nh di can tinh hoan a ro tren mo hoc (Hnh 24-12).29
teratoma thuan nhat. Khoang 95% u tan sinh nguyen phat cua tinh
Cac u mo em. Cac u mo em sinh duc hoan ln hn 1,6 cm ng knh cho thay tang tuan
chiem 3% en 6% tat ca cac u tan sinh cua tinh hoan tren khao sat Doppler mau. Tuy nhien, dau
hoan. Khoang 20% u nay xay ra tre em.15 T u hieu Doppler mau dng nh khong gi vai tro
mo em sinh duc noi en u tan sinh cha te bao quan trong trong anh gia u tinh hoan ngi
Leydig, thecal (vo), granulosa (hat) hoac te bao ln.30 Ngc lai, u tinh hoan tre s sinh co the
lutein (hoang the) va cac nguyen bao si vi mc ang am so vi nhu mo tinh hoan bnh thng va
o biet hoa khac nhau. Cac u nay co the cha mot co the anh gia tot khi dung Doppler mau.31
hay nhieu typ te bao mo hoc do toan nang cua mo Khong the phan biet cac ton thng viem lan toa
em sinh duc.17 Cac u mo em sinh duc ket hp tng vung vi u tan sinh da tren hnh anh Doppler
vi u te bao mam goi la gonadoblastoma (u mau hoac dau hieu Doppler xung.
nguyen bao sinh duc). Phan ln gonadoblastoma Co the phat hien u tinh hoan khong s thay
Bu 799
Hnh 24-11. U te bao Leydig. A, Khao sat cat doc cua na tren cua tinh hoan thay khoi
ac ong nhat, b ro nho (mui ten). B, Mau benh hoc ai the xac nh ban chat la u te bao
Leydig (mui ten).( c phep cua J. William Charboneau, MD., Mayo Clinic, Rochester, Minn.)
benh nhan vo sinh.18 Trong cac trng hp nay,

sieu am cung quan trong trong nh v phau thuat
bang chan oan trong khi mo v co the thc hien
cat u gi lai tinh hoan neu ton thng lanh tnh.
Mot u khong s thay c phat hien tnh c thng
lanh tnh.32 Nhieu ngi tin rang neu cac marker u
hoac hnh X quang ngc bnh thng, cac benh
nhan co the trai qua sinh thiet cat u qua nga ben
gi lai tinh hoan. Neu cat lanh cho thay ton thng
lanh tnh, co the gi lai c quan. Ch nen theo doi
bang sieu am mot ton thng phat hien tnh c neu
lam sang ngh nhieu la ton thng khong phai u
tan sinh (v du co benh s gan ay ve chan thng
hoac nhiem trung).
Di can tinh hoan

Cac di can, leukemia hoac lymphoma. Hnh 24-12. U bung phat thoai trien (regressed
Leukemia (benh bach cau) va lymphoma la cac u burned out). Khao sat cat doc bu thay khoi ac 0,7 cm,
voi hoa, tang am, kem bong lng, S, gia tinh hoan. Thanh
di can tinh hoan thng gap nhat. Lymphoma ac
phan nho phan am kem (mui ten) la carcinoma te bao phoi con
tnh ng v tr th hai trong cac u tinh hoan th sot lai hoac u bung phat.
phat, chiem 1% en 8% tat ca cac u tinh hoan va
la u tinh hoan thng gap nhat phai nam tren 60
tuoi, di can ch xay ra tinh hoan trong 0,3% benh thng gap nhat xay ra tren hai tinh hoan, cung luc
nhan lymphoma.17,33 Tuoi thng xay ra nhat t 60 hoac xay ra mot ben trc trong khoang 6% en
en 70; 80% benh nhan c chan oan tuoi tren 38% cac trng hp. Phan na so u tinh hoan hai
50. Lymphoma ac tnh la u tinh hoan hai ben ben la lymphoma ac tnh.17,19
Lymphoma tinh hoan co the xay ra nguyen

phat ngoai hach, lien quan vi benh di can hoac
benh ly hach tiem an. Khoang 10% benh nhan co
lymphoma khu tru tai tinh hoan.17,33 The
lymphoma tinh hoan nay co tien lng tot hn,
nhng lymphoma he thong phat trien trong khoang
25% benh nhan nay khong lau sau khi bieu hien
hoac sau khi cat bo tinh hoan. So con lai cac benh
nhan co tien lng kem. T le song 5 nam khoang
5% en 20%. Thi gian song trung bnh la 9,5 en
12 thang.34,35
Hau het benh nhan co lymphoma ac tnh bieu
hien bang khoi u tinh hoan khong au hoac tinh
hoan to eu. Khoang 25% benh nhan co trieu
chng chung cua lymphoma nh sot, yeu, kem an
Hnh 24-13. Lymphoma tinh hoan. Khao sat bu cat
hoac sut can. Hau het lymphoma ac tnh cua tinh
ngang cho thay khoi khu tru lympho phan am kem (mui ten)
hoan la loai non-Hodgkin. Theo phan loai cua benh nhan co di can lympho tai bu. Cac vach nho tnh
Rappaport, lymphoma dang lan toa tren mo hoc la hoan bao bi khoi nay. H, tran dch tinh mac.
loai thng gap nhat, theo sau la loai te bao
lympho biet hoa kem.17 Lymphoma loai Hodgkin
rat hiem, ch co bon trng hp c bao cao.36 thng gap trong ca hai benh ly (Hnh 24-14). Cac
Lymphoma tinh hoan thng ln khi chan khoi u khu tru b ro, phan am trong vi hien tng
oan. Tunica vaginalis thng nguyen ven nhng tang am va oi khi co phan am mc thap ben trong
benh lan rong vao mao tinh va thng tinh, chiem a c mo ta trong leukemia te bao lympho
hn 50% cac trng hp.19 Da bu hiem khi b anh man.38 Du sieu am Doppler mau cho thay gia tang
hng. Nhn chung, u khong co vo bao nhng chen tuan hoan trong lymphoma va leukemia tinh hoan,
ep nhu mo ra ti vung ngoai bien. Phan ln khong the phan biet vi tnh trang viem lan toa.39
lymphoma ac tnh ong nhat, phan am kem va lan Cac di can khac. Cac di can khong phai
toa trong tinh hoan.17,33 Tuy nhien, oi khi thay dong lympho ti tinh hoan thng t gap, ch chiem
cac ton thng giam phan am khu tru (Hnh 24-13). 0,02% en 5% tat ca u tinh hoan.40,41 V tr nguyen
Xuat huyet va hoai t hiem. phat thng gap nhat la phoi va tuyen tien liet.19
Leukemia thng la loai u di can tinh hoan Cac v tr nguyen phat khac gom than, da day, ai
ng hang th hai. Leukemia tinh hoan nguyen trang, tu va melanoma.40,42 Hau het di can
phat hiem nhng s xam lan trong qua trnh thoai khong co bieu hien lam sang, kham pha tnh c luc
hoa tuy xng tre em lai thng gap.17,37 Co giai phau t thi hoac sau cat tinh hoan v ung th
ngi tin rang tinh hoan co chc nang nh mot v tuyen tien liet (Hnh 24-15). Di can tinh hoan
tr loc te bao benh trong qua trnh hoa tr v hang thng gap tuoi 60 en 70 va sau tuoi 50 thng
rao te bao sinh duc-mau c che nong o chat hoa gap hn u te bao mam nguyen phat.2,35 Cac u di
tr.37 Tan suat cao nhat lien quan ti tinh hoan gap can thng nhieu va chiem hai ben trong 15%
benh nhan b leukemia cap (64%). Khoang 25% trng hp.19 V u te bao nguyen phat cung co the
benh nhan vi leukemia man co ton thng tinh nhieu cho va hai ben, tnh chat nay khong dung
hoan.38 Hau nh cac trng hp lien quan tinh phan biet u nguyen phat hoac th phat. Cac di can
hoan xay ra trong vong 1 nam khong hoa tr duy tr toan than lan toa thng thay khi co chan oan.39
lau dai lam thoai lui benh. T le tai phat trong Cac ng di can ti tinh hoan bao gom tnh mach
trng hp nay gan 13%.37 ngc dong, ng mau, ng bach huyet ngc
Hnh anh sieu am cua lymphoma va leukemia dong hoac xam lan trc tiep.33,34 Cac v tr pha xa
la khong ac hieu. Tham nhiem lan toa, ln lan tinh hoan nh phoi va da, hau nh lan theo ng
toa, tinh hoan giam phan am la nhng bieu hien mau. Lan theo tnh mach ngc dong qua tnh
Bu 801
Hnh 24-14. Leukemia tinh hoan. Khao sat cat

ngang cho thay tinh hoan trai (L) va phai ( R ) va cho
thay tinh hoan phai to lan toa giam phan am do tham
nhiem benh bach cau (leukemia)
DI CAN TINH HOAN
Lymphoma
Hau het loai non-Hodgkin
10% khu tru tai tinh hoan
Leukemia
Thng th phat
64% cap tnh
V tr quan trong
Di can khong lien quan lymphoma

Thng t phoi va tuyen tien liet
Hnh 24-15. Di can tinh hoan. Hnh cat ngang cho
Than, bao t, ai trang, tuy, melanoma
thay di can (mui ten) giam phan am t phoi en tinh hoan.
mach thng tinh gap trong carcinoma te bao than khong thay bao cao nhieu. Trong 34 u dang nang
va u bang quang va tuyen tien liet.43 U tan sinh c phat hien bang sieu am do Hamm va cs.44, 16
di can ti hach lympho quanh ong mach chu bung ca la u tan sinh. Teratoma la u thng gap nhat co
co the anh hng tinh hoan qua ng bach huyet cha thanh phan dang nang va ac.
ngc dong. Ung th hau mon trc trang thng Nang cua tunica albuginea nam ben trong lp
xam lan trc tiep tinh hoan. ac tnh sieu am cua nay, thng mat trc va ngoai cua tinh hoan.
di can tinh hoan khong phai dong lympho rat a Chung co kch thc thay oi t 2 en 5 mm va
dang. Chung thng co phan am kem nhng cung gii han ro. Chung co the n le hoac nhieu, mot
co the sinh am hoac hon hp.2 thuy hoac a thuy. Thng phat hien benh nhan
50 en 60 tuoi va thng khong co trieu chng.
Cac ton thng lanh tnh trong tinh hoan Ve mat mo hoc, chung la nang n gian, c lot
Cac nang. Nang tinh hoan tnh c phat hien bang te bao khoi hoac cot thap va cha ay huyet
tren sieu am khoang 8% en 10% dan so.44,45 thanh (Hnh 24-16).46-48 Nang phc tap cua tunica
Khong phai tat ca cac ton thng nay eu lanh tnh albuginea co the giong u tan sinh tinh hoan.49 Quet
v cac u tinh hoan co the thoai hoa dang nang do sieu am can than bang nhieu mat cat va co the
xuat huyet hoac hoai t. Phan biet gia nang lanh dung MRI e nhan ra ban chat lanh tnh cua nang
tnh va u tan sinh dang nang rat quan trong tren tunica albuginea.
lam sang. Nang lanh tnh cua tinh hoan c chu y Cac nang trong tinh hoan thng cha thanh
nhieu trong y van nhng u tan sinh dang nang dch vi kch thc thay oi t 2 en 18 mm. Tren
Hnh 24-16. Nang lp vo trang (tunica albuginea).

Khao sat doc bu cho thay nang ngoai bien lp trang b ro,
C, vi tang am pha xa. Hnh 24-17. Cac nang lanh tnh trong tinh hoan.
Khao sat cat doc cho thay hai nang trong tinh hoan va
nang mao tinh (mui ten).
sieu am, ton thng gii han ro%, phan am trong bao gom nhieu nang ket noi co hnh dang kch
vi thanh mong, trn lang va co tang am pha sau. thc thay oi, ngan cach nhau bi cac vach ngan
Hamm va cs.44 bao cao trong 13 trng hp cua ho, x.59 Ton thng co nguon goc tai li tinh hoan
cac nang nam gan trung that tinh hoan, cung co ly lan vao nhu mo ke can, dan ti teo nhu mo xung
thuyet cho rang nang co nguon goc t li tinh quanh do ap lc. Cac nang c lot bi mot lp
hoan, co the th phat sau chan thng hoac tao hep duy nhat bieu mo phang hoac hnh lap phng. Vo
sau viem (Hnh 24-17).44,46 sinh than hoac loan san than thng xay ra ong
Gian ong li tinh hoan. Co the chan oan thi vi loan san dang nang tinh hoan.59
lam gian ong li tinh hoan vi u tan sinh.52-57 Nang dang bieu b (epidermoid). Cac nang
Gian ong thng i kem vi tac nghen mao tinh epidermoid la cac u lanh tnh co nguon goc te bao
th phat sau viem hoac chan thng. Ton thng mam, chiem khoang 1% tat ca u tinh hoan. Cac u
dang nang vi kch thc thay oi trong vung trung nay co the xay ra bat c tuoi nao nhng thng
that tinh hoan khong kem theo bat thng mo mem nhat la t 20 en 40 tuoi.19,60,61 Benh nhan thng
hoac khong co dong chay tren Doppler mau (Hnh bieu hien mot not tinh hoan khong au; mot phan
24-18). Mot so ln bat thng loai nay xay ra hai ba tnh c phat hien khi kham lam sang. 10% cac
ben va thng i kem vi nang tinh dch cung ben. trng hp co tinh hoan ln toan bo khong au.60,62
Hnh anh sieu am ac trng va v tr giup phan biet Cac ton thng nay thng la u ac gii han ro
tnh trang lanh tnh nay vi ac tnh, do vay tranh nam di tunica albuginea. Ve benh hoc, thanh u
phai cat bo tinh hoan. Dau hieu MRI ac trng bao gom mo si vi lp lot ben trong la bieu mo te
bao gom cng o tn hieu bat thng trong tinh bao vay. Nang nay cha ay keratin trang nga
hoan tng t nh tn hieu cua nc trong vung giong nh tuyet.
trung that tinh hoan.54 Ngi ta tin rang nang epidermoid bieu hien s
Loan san dang nang. Loan san dang nang la phat trien n thai hoac n b cua teratoma doc
d dang bam sinh hiem gap thng xay ra tre s theo tien trnh biet hoa te bao ngoai b. Ch co the
sinh va tre nho du a co bao cao mot ca 30 tuoi.58 phan biet ton thng lanh tnh nay vi teratoma ac
Ch co 8 trng hp c mo ta.59 Ngi ta tin tnh qua khao sat mo hoc. Theo nh ngha, nang
rang ton thng nay hnh thanh do khiem khuyet epidermoid khong cha thanh phan cua teratoma
phoi hoc ngan can ket noi cac ong trong li tinh va do vay khong co nguy c ac tnh.
va cac ong ly tam. Ve mat benh hoc, ton thng Ve mat sieu am, nang epidermoid thng la
Bu 803
Hnh 24-18. Gian li tinh. Hnh cat doc cho thay

thay oi dang nang cac ong (mui ten) trong phan sau tinh
hoan, T.
khoi ac, phan am kem, gii han ro oi khi co

phan am day ben trong. Khoi u nay ien hnh co
vo bao tang am (Hnh 24-19).61,62 Du hnh anh
tng oi ac trng, cung khong the loai tr hoan
toan tnh ac neu ch da tren dau hieu sieu am.
Ngi ta con ang tranh cai cho viec ieu tr ung
loai ton thng nay. Phng phap bao ton cha lai
tinh hoan vi cat bo khu tru (boc nhan) hoac cat
tinh hoan gian n hoac tan goc co the thc
hien.60,64 Ch co the phan biet vi teratoma qua
khao sat benh hoc thanh nang va tinh hoan ke
can.60 Cat bo tinh hoan co t le song 100% va
khong can phng phap ieu tr khac.
Ap xe. Ap xe tinh hoan thng la bien chng
cua viem tinh hoan-mao tinh; cung co the do tinh
hoan xoan bo sot, u hoai t hoac nhiem trung. Cac
nguyen nhan nhiem trung thng gap tao ap xe la
quai b, au mua, sot hong ban, thng han,
cum, viem xoang, viem tuy xng, viem ruot Hnh 24-19. Nang epidermoid lanh tnh. Khao sat cat
tha va cac nguyen nhan khac.65 Ap xe tinh hoan doc tinh hoan cho thay nang keratin b ro kem thanh tang
phan am trn lang (mui ten) va cac chat phan am ben trong.
co the v qua tunica vaginalis, tao o mu hoac tao
Khi phau thuat, nang epidermoid co boc ro lanh tnh cha
do ra da. cac chat set co voi hoa vo bao. Hnh anh sieu am lanh tnh
Sieu am thng cho thay tinh hoan ln cha tao khoang trong tinh hoan. (c phep cua Ben
mot khoi ay dch vi nhng vung phan am kem Hollenberg, M.D., Benh vien Presbyterian, Charlotte, NC.)
hoac hon hp thay c (Hnh 24-20). Ngi ta
cung mo ta hnh anh khong ien hnh theo o cau
truc tinh hoan b pha v vi cac van tang phan am oan ap xe tinh hoan nhng thng co the phan
ngan cach cac khoang phan am kem (Hnh 24- biet vi u bang trieu chng lam sang.
21).66 Ngi ta tin rang nhng van nay la cac vach oi vi benh nhan b hoi chng suy giam mien
ngan si tach nhu mo tinh hoan hoai t phan am dch (AIDS), kho phan biet ap xe vi u tan sinh
kem. Khong co cac tnh chat sieu am giup chan tren khao sat sieu am. Cac dau hieu lam sang co
Hnh 24-20. Ap xe tinh hoan ien hnh. Ap xe tinh hoan phan am kem (mui ten) khong the
phan biet vi u. Tuy nhien, tang am pha xa (mui ten cong) cho thay khoi u chu yeu la dch.
CAC TON THNG DANG NANG

CUA TINH HOAN
Lanh tnh
Nang lp trang
Nang trong tinh hoan
Gian dang ong cua li tinh
Loan san dang nang
Nang thng b
Ap xe
Ac tnh
Hnh 24-21. Ap xe tinh hoan khong ien hnh. Hnh
Teratomacarcinoma
dang khong ien hnh cua ap xe tinh hoan (mui ten cong) co
U tui noan hoang
thanh phan phan am va phan am kem. H, tran dch tinh mac
Hoai t/xuat huyet trong u hai ben
U gay tac ong
Lymphoma
the co ch; tuy nhien, cat tinh hoan thng can thiet thc bnh thng phan am kem. Khoi phan am
e co chan oan mo hoc. kem khu tru khong the phan biet u tan sinh neu ch
Nhoi mau. Nhoi mau tinh hoan co the xay ra da tren hnh anh. Cac ton thng nay thng
sau xoan, chan thng, viem noi tam mac do vi khong co tuan hoan, phu thuoc thi gian nhoi mau.
trung, viem a ong mach dang not, leukemia, tnh Neu mot khoi giam phan am,g ii han ro, khong s
trang tang ong va ban xuat huyet Henoch- thay, nam tng oi ngoai bien, hoan toan khong
Schonlein. Nhoi mau tinh hoan t phat hiem gap. co tuan hoan tren sieu am Doppler nang lng
Hnh anh sieu am phu thuoc vao thi gian nhoi hoac sau khi chch chat tng phan, co the phan
mau. Khi au nhoi mau co hnh anh khoi phan biet nhoi mau lanh tnh o vi cac u tan sinh
am kem khu tru hoac toan bo tinh hoan vi kch nhng benh nhan co trieu chng lam sang thch
Bu 805
Hnh 24-22. Nhoi mau tinh hoan. A, Sieu

am doc bu cho thay khoi phan am kem bien gii
ro nam ngoai bien khong co tuan hoan (mui ten).
B, Khao sat lap lai cho thay khoi (++,XX) va toan
bo hai tinh hoan giam kch thc. C, Doppler nang
lng khong thay dong chay trong vung nhoi mau
(mui ten)
hp (Hnh 24-22). Tuy nhien, oi hoi nhieu kinh hoan hoac mao tinh (Hnh 24-24).5,74 oi khi thay
nghiem e minh chng gia thuyet nay. Theo thi dang not phan am day voi hoa kem bong lng.
gian, khoi phan am kem hoac toan bo tinh hoan Chan oan phan biet kho vi qua trnh viem hoac
nho lai va phat trien cac vung tang phan am v qua u tan sinh bang sieu am n thuan. Boc tach hoac
trnh x hoa hoac voi hoa loan dng (Hnh 24- cat bo tinh hoan co the can thiet e chan oan xac
23).9,66,70 Hnh anh sieu am giai oan au co the nh.
kho khan trong chan oan phan biet vi u tan sinh Manh sot tuyen thng than. Tang san
tinh hoan nhng nhoi mau giam kch thc theo thng than bam sinh la benh ly di truyen theo
thi gian trong khi u lai ln len theo thi gian.2,73 autosom lan lien quan ti khiem khuyet men vo
Sarcoidosis. Benh sarcoid co the anh hng thng than. Benh nay co the co trieu chng lam
ti mao tinh, con tinh hoan t b hn. Ton thng sang sm hoac tuoi trng thanh. Bieu hien lam
sinh duc chiem di 1% so benh nhan co sang thng la khoi u trong tinh hoan hoac tinh
sarcoidosis he thong.2,9 Bieu hien lam sang la hoan to, day th sm, co kem hoac khong kem tnh
viem mao tinh cap hoac tai phat hoac tinh hoan trang mat muoi. Adrenal rests co nguon goc t te
hoac mao tinh ln khong au. Sieu am cho thay bao vo thng than lac cho xam nhap vao mo sinh
hnh anh khoi phan am kem khong eu trong tinh duc bao thai. Chung tao nhng khoi u ap ng
Hnh 24-24. Sarcoid tinh hoan. Khao sat cat doc tinh
Hnh 24-23. Nhoi mau man cua tinh hoan. Khao sat
hoan cho thay khoi ac nho phan am kem (mui ten) ac
ngang tinh hoan b nhoi mau man cho thay cac vung tang (mui
trng cua benh sarcoidosis. (c phep cua J. Williams
ten) va giam am (mui ten cong) khong the phan biet vi u ac
Charboneau, M.D, Mayo clinic, Rochester, Minn.)
tnh.
vi tnh trang tang ACTH do tang san thng than

bam sinh va hoi chng Cushing va hiem khi
chuyen ac tnh. Sieu am cho thay nhieu ton thng
phan am trong. oi khi co bong lng (Hnh 24-25).
Nhieu manh sot tuyen thng than co tuan hoan
vi nhieu mach mau vung ngoai bien hng tam
dang nan hoa trong khoi u. Neu benh nhan a biet
co bat thng thch hp ve hormone lien quan ti
tang san thng than bam sinh va neu sieu am cho
thay cac dau hieu phu hp, trong a so cac trng
hp, khong can khao sat them.75,76
Voi hoa bu. Voi hoa bu co the thay ben
trong nhu mo tinh hoan, tren be mat tinh hoan hoac Hnh 24-25. Cac u te bao sot lai cua vo thng
nam t do trong dch chen gia cac lp cua tunica than. Khao sat doc bu cho thay nhieu khoi khu tru (mui
vaginalis. Voi hoa to trn lang khong kem khoi u ten) va phan am kem (au mui ten) trong tinh hoan. Hnh
dang nay khong phan biet c vi u ac tnh khac va tng
mo mem gi y u te bao Sertoli te bao ln, voi hoa
t vi u te bao sot lai mao tinh hoac thng tinh.
mac du oi khi u te bao mam bung phat co the
co hnh anh tng t.77 Voi hoa rai rac co the gap
trong lao, giun ch va seo t u te bao mam thoai hoa cac the giong the tinh bot (corpora amylacea)
trien hoac chan thng. co the tm thay trong ong sinh tinh cua tinh hoan an
Soi li ti cua tinh hoan la tnh trang khong hoac tinh hoan xuong bnh thng.81 Sieu am cho
thng gap, theo o not voi hien dien ben trong thay vo so o nho, tang phan am lan toa rai rac
cac ong sinh tinh.9 Nhng om voi nay xay ra trong nhu mo tinh hoan, hiem khi kem bong lng
tinh hoan bnh thng va tinh hoan an va tng c va oi khi thay uoi sao choi. Co the xay ra ca hai
bao cao trong hoi chng Klinefelter, lng tnh ben (Hnh 24-26).
gia nam va u tan sinh tinh hoan.78-80 Ngi ta a Luc au, ngi ta cho rang soi li ti cua tinh
chng minh rang cac soi li ti nay do qua trnh voi hoan la mot dien tien lanh tnh vi hnh anh sieu
Bu 807
Hnh 24-27. Voi hoa tinh hoan. khao sat doc bu

benh nhan khong trieu chng thay tinh hoan T va mao tinh
E bnh thng, va dch tinh mac, H. not voi khu tru b ro
tnh c phat hien va co le lien quan ti viem nhiem trc
ay hoac tao u hat te bao tinh v khong co thay oi trong 6
thang.
CAC NOT VOI TRONG BU
Tinh hoan
Ran, u hat sau viem, not voi nho mach mau
U te bao mam burned out
U te bao Sertoli voi hoa ln
Teratoma/teratocarcinoma
Sarcoid
Lao
Nhoi mau man
Hnh 24-26. Not voi nho trong tinh hoan tien ung
th tinh hoan. A, Khao sat benh nhan nam 27 tuoi co
Ngoai tinh hoan
benh s au tinh hoan nhe cho thay soi li ti trong tinh hoan
(mui ten). B, Khao sat theo doi 1 nam sau cho thay
Voi bu lp mac nong
carcinoma te bao hon hp seminona-phoi (mui ten) . T, tinh Viem mao tinh man
hoan bnh thng. Soi li ti (au mui ten). Schistosomiasis
am ac trng khong oi hoi anh gia them. Tuy

nhien, cac bao cao gan ay cho thay tnh trang xay nhng benh nhan co soi li ti tinh hoan tr thanh
ra ong thi ang lu y gia u tan sinh tinh hoan thng qui moi 6 thang kem anh gia marker u
nguyen phat va soi li ti tinh hoan.83,84 Trong mot thch hp.
nghien cu, 40% trong so 42 benh nhan co soi li ti Soi li ti rieng le tc co t hn nam not voi n
tinh hoan co u tan sinh i kem. Do vay, soi li ti gian trong moi tinh hoan la mot tnh trang thng
khong con c xem la mot nhan nh lanh tnh gap, co the lanh tnh lien quan ti viem nhiem,
tnh c. Mot trng hp gan ay tai vien cua granuloma hoac mach mau (Hnh 24-27). Hien tai,
chung toi cho thay u te bao mam nguyen phat neu co t hn nam soi li ti tren mot mat cat, khong
phat trien mot nam ri sau khi nhan nh soi li ti c phep chan oan soi li ti cua tinh hoan va theo
khong lien quan u. Hien tai, sieu am theo doi doi benh nhan co le khong can thiet.
Soi bu ngoai tinh hoan phat sinh t be mat nc tieu co the tch tu gia lp tang va thanh cua
cua tunica vaginalis va co the bong ra di chuyen tunica vaginalis lot trong bu. Cac khoi tu dch nay
gia hai lp cua tunica nay (Hnh 24-28). Chung thng phan trc ngoai cua bu v tinh hoan
c goi la the long leo dang fibrin hoac hat ngoc dnh vao mao tinh va thanh bu pha sau (vung
bu v hnh anh ai the tron, trang ngoc. Ve mo tran) (Hnh 24-30).
hoc, chung bao gom chat lieu dang fibrin lang Bu bnh thng cha vai mililt thanh dch
ong quanh mot nhan trung tam hydroxyapatite.85 nam gia cac lp cua tunica vaginalis. Khoang
Chung co the do viem tunica vaginalis hoac xoan 85% benh nhan khong trieu chng khi c sieu
mau phu tinh hoan hoac mao tinh. Thng gap am bu thay lng dch nho mot na bu.86
tran dch tinh mac th phat v c che s bai tiet va Tran dch tinh mac la s tch tu bat thng
hap thu bnh thng cua tunica vaginalis, thng do thanh dch, la nguyen nhan thong thng nhat cua
qua trnh viem. Hnh thanh dch tinh mac giup bu sng to3 khong au va co the do mac phai hoac
chan oan soi bu de dang hn. (Hnh 24-29). bam sinh. Loai bam sinh la do qua trnh ong lp
vaginalis khong hoan toan, tao lo thong noi ton tai
Benh ly ngoai tinh hoan gia bu va khoang phuc mac ma thng ong lai
Tran dch tinh mac, tran mau tinh mac va khoang 18 thang tuoi.
tu mu trong tinh mac. Thanh dch, mau, mu hoac Tran dch tinh mac mac phai thng do chan
nc tieu co the tch tu gia lp tang va thanh cua thng chiem 25% en 50% cac trng hp. t khi
tran dch lng ln do u tan sinh, trong khi tran
dch tinh mach lng t xay ra trong 60% benh
nhan b u tinh hoan.2,4,87 Cac nguyen nhan khac
bao gom viem mao tinh, viem tinh hoan-mao tinh,
va xoan tinh hoan.9,21
Sieu am ong vai tro quan trong v no co the
phat hien nguyen nhan tiem an va cho phep anh
gia tinh hoan khi tran dch lng ln can tr viec
s nan. Tran dch tinh mac la khoi tu phan am
trong ac trng kem tang am pha xa quanh mat
trc ngoai cua tinh hoan, tao ca so am hoc tot
Hnh 24-28. Mang voi hoa t tinh mac (tunica

vaginalis). Cat doc cho thay ong voi tunica vaginalis
(mui ten).
Hnh 24-29. Soi bu. Khao sat cat doc bu thay tinh
hoan khong ong nhat (mui ten) benh nhan co nhieu t Hnh 24-30. Tran dch tinh mac. Khao sat cat ngang bu
viem mao tinh cap va man. Tran dch tinh mac phan ng cho thay tran dch tinh mac, H, bao quanh tinh hoan tr phan
lng t, H, cha soi bu tang am, troi noi t do (mui ten pha sau (mui ten) ni tinh hoan dnh trc tiep vao thanh bu.
cong). Soi s thay c nay la ly do i sieu am.
Bu 809
cho khao sat hnh anh tinh hoan. Phan am mc o hoan, doc theo mao tinh va ong dan tinh ben trong
thap ti trung bnh do cac the fibrin hoac tinh the thng tinh (Hnh 24-32).3,4,9,49 cac tnh mach cua
cholesterol oi khi thay di chuyen t do ben trong am roi tnh mach dang tua cuon nay thng co
dch tinh mac.4,13 ng knh 0,5 en 1,5 mm va tnh mach dan lu
Tran mau va tu mu tinh mac t gap hn so chnh co the ti 2 mm.
vi tran dch tinh mac n gian. Tran mau co the Co hai loai gian tnh mach thng tinh: nguyen
do chan thng, phau thuat, tieu ng, u tan sinh, phat (khong ro can nguyen) va th phat. Gian
xoan hoac benh ly x va.88 Tran mu do v ap xe tnh mach thng tinh khong ro can nguyen do
vao dch tinh mach san co hoac v trc tiep vao suy van trong tnh mach thng tinh tao dong chay
gia cac lp cua tunica vaginalis. Ca hai tran mau ngc t thng tinh vao am roi tnh mach dang
va tran mu co vach ben trong va tao thuy (Hnh 24- tua cuon. No la nguyen nhan thong thng nhat
31). Day da bu va voi hoa co the gap trong trng gay vo sinh co the ieu tr c, chiem 21% en
hp man tnh. 39% so an ong tai khoa vo sinh.90-92 Gian tnh
Gian tnh mach thng tinh (varicocele). mach thng tinh khong ro can nguyen xay ra ben
Gian tnh mach thng tinh la tnh trang tap trung trai chiem 98% va thng gap nam tuoi t 15
cac tnh mach gian bat thng, dai, uon khuc cua en 25.9 Xay ra u the ben trai la do dan lu tnh
am roi tnh mach dang tua cuon nam pha sau tinh mach ben trai o vao tnh mach than trai nghch
vi tnh mach thng tinh ben phai o vao tnh
mach chu di. Cac bui gian nay thng noi ro khi
benh nhan ng hoac lam nghiem phap Valsalva
hoac co the xep xuong khi benh nhan nam nga.
Gian nguyen phat hai ben chiem ti 70% cac
trng hp.93
Gian tnh mach thng tinh th phat do tang
ap lc tren tnh mach thng tinh hoac cac nhanh
cua no bi than nc ang ke, gan to, u vung bun
hoac chen ep tnh mach bi u sau phuc mac.4,21
Trong cac trng hp gian ben phai, khong e xep
hoac mi phat hien benh nhan tren 40 tuoi, v
nhng trng hp nh vay hiem khi khong can
nguyen, nen phai tm u gay tac nghen hoi lu tnh
mach sinh duc.3 Hnh anh gian tnh mach thng
Hnh 24-31. Tran mu tinh mac. Khao sat ngang qua
phan tren cua tinh hoan phai benh nhan co viem mao tinh
tinh th phat khong anh hng bi t the benh
va tao ap xe tinh hoan cho thay tran mu tinh mac, P, kem nhan.
nhieu vach ben trong (mui ten) va manh vun (mui ten m). benh nhan vo sinh nam, sieu am giup chan
Viem mau phu mao tinh phu ne co the thay (mui ten cong).
Hnh 24-32. Gian tnh mach thng tinh. A, Khao sat doc cho thay gian tnh mach ngoan
ngoeo (mui ten) . B, Hnh anh Doppler mau cho thay dong chay trong tnh mach gian. T, tinh hoan.
oan gian tnh mach thng tinh thay hoac khong

thay ro tren lam sang. Khong co s tng quan
gia kch thc gian tnh mach va mc o ton
thng tinh hoan dan ti vo sinh. Do vay tam soat
sm va ieu tr gian tnh mach khong ro tren lam
sang la rat quan trong.92
Trong gian tinh mach thng tinh, sieu am cho
hnh anh cau truc phan am trong ngoan ngoeo
ng knh ln hn 2 mm tao nen vung tap trung
nhieu nang uon khuc nam ke can hoac gan cc
tren cua tinh hoan va au mao tinh. oi khi gian
tnh mach hien len giong nh nang thng tinh nho
co vach ngan, Phan biet gian tnh mach thng tinh
hoac nang thng tinh bang sieu am duplex hoac
sieu am Doppler mau. Tng t, co the phan biet
tnh mach gian trong trung that tinh hoan vi gian Hnh 24-33. M mac noi thoat v, H, nam tren tinh
cac ong li tinh hoan nh sieu am mau va hoan phai, T.
Doppler xung. au do tan so cao vi che o cai
at cho dong chay cham e toi u hoa viec phat
hien dong chay cham trong tnh mach gian. Co the
thay te bao hong cau di chuyen cham bang au do
tan so cao ngay ca khi dong chay qua cham kho
phat hien c bang Doppler (xem Hnh 24-32).
Dong chay tnh mach co the tang khi benh nhan
ng hoac ap dung nghiem phap Valsalva. Hn
na, gian tnh mach thng tinh khong giong nang
thng tinh, chay doc theo thng tinh vao trong ong
ben va de dang b ep bang au do.2,4,21
Thoat v bu. Thoat v bu la khoi quanh tinh
hoan thng gap. Du thoat v bu thng chan Hnh 24-34. U adenomatoid, uoi cua mao tinh.
oan da tren benh s va tham kham lam sang, Khao sat cat doc bu cho thay tinh hoan bnh thng, T, va
au cua mao tinh, E, vi khoi ln, phan am kem, b ro, A,
sieu am rat hu dung trong anh gia cac trng trong uoi mao tinh.
hp khong ien hnh. Thoat v co the la ruot non,
ai trang, hoac mac noi. Sieu am co the xac nh
s hien dien quai ruot trong thoat v bang hnh anh nay.16,95 U thng v tr mao tinh, nhat la vung
nep niem mac (ruot non) hoac ngan thanh mac (ai uoi nhng co the thng tinh hoac lp bao tinh
trang) va thay nhu ong ruot trong khao sat thi hoan (Hnh 24-34).18 U tan sinh nay co the xam
gian thc. Neu khong co cac hnh anh tren, chan nhap vao nhu mo tinh hoan lan can. No co the xay
oan phan biet vi u a nang khac ngoai tinh hoan ra bat ky tuoi nao, nhng thng thay tuoi 20
nh tran mau va mu tinh mac co the kho khan. en 50.2,18,96 No thng mot ben n oc, b ro va
Hnh anh phan am day trong bu co the la mac noi hnh tron hoac bau duc hiem khi o nho hn 5cm
hoac khoi m khac (Hnh 24-33). Phai thc hien ng knh. oi khi no co dang mang hoac khong
sieu am vung ong ben e xac nh s keo dai cua xac nh ro. Sieu am thng cho hnh anh khoi u
quai ruot hoac mac noi t ong ben vao trong ac b ro co mc o phan am bang hoac hn tinh
bu.21,94 hoan.2 No cung co the giam phan am.
Cac u. U tan sinh ngoai tinh hoan hiem va Cac u lanh tnh khac ngoai tinh hoan hiem gap
thng lien quan ti mao tinh. U thng gap nhat bao gom fibroma, hemangioma, lipoma, leio-
la u dang tuyen adenomatoid, chiem 32% cac u myoma, neurofibroma va granuloma cholesterol
Bu 811
Hnh 24-35. Lymphosarcoma nguyen phat cua thng tinh. A, khoi u ln, chac
s c xac nh u ngoai tinh hoan dang ong khong ong nhat (++) trong thng tinh. viem
tinh hoan-mao tinh nang va tran mu tinh mac, P. B, hnh anh giong thng tinh (mui ten)
thng to ra va khong ong nhat trong viem tinh hoan-mao tinh, nhng khong s c khoi
u chac va cac dau hieu ap ng ro vi ieu tr.
Manh sot tuyen thng than co the thay trong trong CAC U NGOAI TINH HOAN
thng tinh, tinh hoan, mao tinh, li tinh hoan va
tunica albuginea (lp vo trang) trong khoang 10% Lanh tnh
tre s sinh. U adenomatoid
Cystadenoma dang nhu cua mao tinh co the Fibroma
thay benh nhan b benh Hippel-Lindau.74 U tan Lipoma
sinh ac tinh ngoai tinh hoan nguyen phat bao gom Hemangioma
Leiomyoma
fibrosarcoma, liposarcoma, va t gap hn la
Neurofibroma
histiocytoma ac tnh va lymphoma ngi trng
Granuloma cholesterol
thanh va rhabdomyosarcoma tre em (Hnh 24- Manh sot tuyen thng than
35). Cystadenoma dang nhu
U di can ti mao tinh cung hiem gap. V tr
nguyen phat thng gap nhat la tinh hoan, da day, Ac tnh
than, tuyen tien liet, ai trang va t hn na la tuy. Fibrosarcoma
Sieu am cho thay vung phan am khu tru trong mao Liposarcoma
tinh thng kem tran dch tinh mac. Rhabdosarcoma
Histiocytoma
Lymphoma
Cac ton thng mao tinh
Di can
Ton thng dang nang. Nang thng tinh
thng gap nhieu hn nang mao tinh. Ca hai gap
trong khoang 20% en 40% trng hp benh nhan
khong trieu chng theo nghien cu cua Leung va sa.2,74 Ca hai ton thng co the do tng t viem
cs.86 va 30% la nhieu nang. Cac nang mao tinh va nhiem hoac chan thng. Nang thng tinh va nang
nang thng tinh c cho la gian cac ong mao tinh mao tinh co hnh anh giong nhau tren sieu am:
nhng thanh phan cac khoi nay khac nhau.3,74 khoi phan am trong b ro khong co hoac co t phan
Nang cha thanh dch trong trong khi nang thng am ben trong (Hnh 24-36). Thng thay cac
tinh cha tinh trung va te bao lympho co can lang, khoang va vach ngan (Hnh 23-37) va phan biet
the m va manh vun te bao lam dch ac nh gia nang thng tinh va nang mao tinh khong quan
Hnh 24-36. Nang mao tinh. Khao sat doc bu thay nang
mao tinh (mui ten) lien quan ti au mao tinh, khong the phan
biet vi nang thng tinh.
trong tren lam sang. Nang thng tinh thng xay

Hnh 24-37. Nang thng tinh. Khao sat cat doc au
ra au mao tinh trong khi o nang mao tinh doc mao tinh cho thay nang thng tinh, S, cha nhieu vach (mui
theo chieu dai mao tinh. ten). T, tinh hoan
Granuloma tinh trung. Ngi ta tin rang
granuloma tinh trung phat sinh t s that thoat tinh hoa trong lp tunica albuginea hoac mao tinh.2,103
trung ra ngoai vao trong mo mem quanh mao tinh Viem mao tinh dang hat khong ieu tr lan ti tinh
tao phan ng dang hat hoai t.2,99,100 Cac ton hoan trong 60% en 80% trng hp.9 Ton thng
thng nay thng khong co trieu chng nhng tinh hoan khu tru co the giong hnh anh u tan sinh
thng lien quan ti nhiem trung hoac chan thng tren sieu am trong khi ton thng tinh hoan lan toa
mao tinh. Chung thng thay benh nhan sau khi tao hnh anh tinh hoan to, khong eu vi o phan
that ong dan tinh. Hnh anh ien hnh la khoi ac am giam ong nhat.
phan am kem trong mao tinh mac du chung co the
giong ton thng trong tinh hoan.99 BENH LY CAP TINH CUA BU
Cac thay oi mao tinh sau that ong dan
tinh. Cac thay oi mao tinh tren sieu am c bao Xoan
cao trong 45% benh nhan sau that ong dan tinh. Co rat nhieu chan oan phan biet cho mot bu sng
cac dau hieu bao gom mao tinh ln, khong ong to au, bao gom xoan thng tinh va tinh hoan, xoan
nhat va phat trien granuloma tinh trung va nang. mau phu tinh hoan, viem mao tinh va/hoac viem
Co ly thuyet cho rang that ong dan tinh tao gia tinh hoan, tran dch tinh mac cap, thoat b ket, phu
tang ap lc trong ong mao tinh gay v ong tao lap bu khong ro can nguyen, ban xuat huyet Henoch-
sperma granuloma. Tnh trang v ong nay co the Schonlein, ap xe, xuat huyet do chan thng, xuat
bao ve tinh hoan khoi tnh trang tang ap lc ngc. huyet trong u tan sinh va hoai t m trong bu.
Dau hieu sieu am khong ac hieu va co the thay Xoan thng tinh va viem mao tinh cap hoac viem
trong viem mao tinh.101 Dau hieu sieu am sau cat tinh hoan-mao tinh la nguyen nhan thng gap
tinh hoan bao gom khoi mau tu, tai phat u khu tru, nhat cua bu cap. Tren 50% cac nguyen nhan nay
u nguyen phat th phat va hnh anh sieu am cua khong the phan biet tren lam sang hoac xet
tinh hoan nhan tao.102 nghiem.104 Xoan thng gap tre em nhng ch
Viem mao tinh man tnh. Benh nhan b viem chiem khoang 20% benh ly bu cap nam sau day
mao tinh cap do vi trung ieu tr khong hoan toan th.2 Chan oan chnh xac la can thiet v xoan can
thng bieu hien khoi bu au man tnh. Benh phau thuat ngay e bao ton tinh hoan. T le bao
nhan vi viem mao tinh dang hat man tnh do lao ton chiem 80% en100% neu phau thuat thc hien
lan toa t ng nieu-duc bieu hien bang u bu trong vong en 6 gi sau khi khi phat, 70% trong
chac, khong au.3 Sieu am thng thay da bu day, vong 6 en12 gi va ch 20% sau 12 gi. Phau
mao tinh to day khong eu. Co the nhan ra voi thuat tham sat ngay tc th ch nen thc hien oi
Bu 813
vi tre em va thanh nien b au bu cap khi khong

co chan oan xac nh viem mao tinh hoac tinh
hoan. Phng phap nay lam tang t le bao ton
nhng cung gia tang cac phau thuat khong can
thiet.106 Chup phong xa hat nhan, sieu am thi
gian thc va sieu am Doppler lam tang o chnh
xac trong chan oan phan biet gia nhiem trung va
xoan.107 Sieu am hien tai, dung Doppler mau
va/hoac mode nang lng la phng phap hnh anh
hoc c chon e chan oan nguyen nhan au bu
cap ngi trng thanh.
Co hai loai xoan tinh hoan: xoan trong hoac
ngoai bao. Xoan trong bao la loai thng gap
nhat, xay ra hau het tuoi day th. Xoan nay do
cho treo bat thng cua tinh hoan bang mot cuong
dai cua thng tinh, tao ra s bao phu toan bo tinh Hnh 24-38. Xoan tinh hoan. Khao sat cat ngang bu
cho thay tinh hoan trai, L, va mao tinh to ra ro va phan am
hoan va mao tinh bi tunica vaginalis. No giong
kem so vi tinh hoan ben phai bnh thng. Co the thay cac
nh cai chuong va o go. Co t le ln hn cua dau hieu tng t trong trng hp nang cua viem tinh hoan-
xoan trong tinh hoan an sau khi phau thuat em mao tinh hoac viem mao tinh.
xuong. Treo tinh hoan bat thng cung xay ra
trong 50% en 80% tinh hoan oi ben.21 tunica vaginalis, trong mao tinh hoac cac v tr
Xoan ngoai bao thng xay ra tre s sinh ngoai tinh hoan khac c ghi nhan trong nhieu
khong co bien dang chuong va o go. No c trng hp xoan bo sot. Cac dau hieu thang xam
cho rang do tnh di ong cua toan bo tunica cua xoan cap hoac ban cap khong ac hieu va co
vaginalis tao xoan tinh hoan va lp bao ngang the thay trong nhoi mau tinh hoan th phat sau
vong ngoai. Cac tnh mach thng tac nghen trc viem mao tinh, viem tinh hoan-mao tinh va v
cac ong mach ca hai loai xoan, tao phnh to sm hoac nhoi mau tinh hoan do chan thng.
cac mach mau va phu ne tinh hoan. Khao sat Doppler xung va mau cua thng tinh
Pho cua bien oi sieu am thang xam c bao va mach mau tinh hoan thng dung e phan biet
cao trong xoan tinh hoan giai oan cap trong xoan vi viem tinh hoan-mao tinh (Hnh 24-
vong 1 en 6 gi.104,109 Tinh hoan tr nen to, khong 39).104,111,115,116 Tren ly thuyet, s hien dien dong
ong nhat va giam phan am khi so sanh vi tinh chay bnh thng hoac tang trong tinh hoan giup
hoan oi ben (Hnh 24-38). Cac dau hieu ngoai loai tr chan oan xoan tinh hoan cap. Can khao
tinh hoan thng gap bao gom mao tinh ln cha sat t m nhu mo tinh hoan va s dung ky thuat
cac not tang hoac giam am, da day va tao dch tinh Doppler dong chay cham v mach mau tinh hoan
mac phan ng. oi khi, tinh hoan co the co phan nho va co van toc cham.
am bnh thng.110-112 Tang o phan am tinh hoan Chan oan thieu mau tinh hoan phu thuoc
lan toa c bao cao trong hai trng hp xoan cap vao kha nang ch ro hien dien dong chay bnh
khong co thay oi mo hoc cua xuat huyet tinh hoan thng trong tinh hoan oi ben bnh thng khong
hoac nhoi mau.104-113 trieu chng. Hang loat nghien cu gan ay bao
Trong giai oan ban cap cua xoan (1 ti 10 cao cac dau hieu Doppler mau trong thieu mau
ngay), mc o giam phan am tinh hoan va kch tinh hoan.116,117 Mot nghien cu bao cao vi o
thc tang trong vong nam ngay au sau o giam nhay 86% va o chuyen biet 100% va o chnh xac
trong 4 en 5 ngay tiep theo. Mao tinh thng van 97% trong chan oan xoan tinh hoan khi s dung
to nhng tang am. Tran dch tinh mac thng gap sieu am Doppler mau.117 Hn na, xoan mau phu
trong xoan man.109 Trong bao cao gan ay cua tinh hoan c chan oan chnh xac trong 5 benh
Vick va cs.113, cac khoi ln ngoai tinh hoan tang nhan do vay ieu tr bao ton va loai bo cac phau
phan am hoac hon hp do xuat huyet ben trong thuat khong can thiet.116 Nghien cu nay cung bao
Hnh 24-39. Xoan tinh hoan cap cua tinh hoan trai. A, Khong co dong chay mau trong tinh
hoan, T, va dong chay nho vung au mao tinh (mui ten). Nhu mo giam phan am. H, tran dch tinh
mac. B, tinh hoan phai khong trieu chng thay dong chay va mc o phan am bnh thng.
cao mot trng hp am tnh gia vi dong chay phat 360 o nhng t nhat xoan 540 o mi lam tac
hien ctrong tinh hoan nhng khi phau thuat nghen hoan toan mach mau en tinh hoan.118,119
phat hien a xoan. Thu v hn, thng tinh xoan Do vay xoan vi goc o nho, dong chay nho co the
Bu 815
ton tai trong tinh hoan. Khi xoan tien trien, dang
song ong mach bnh thng tr nen cong vom
tardus parvus, tao dang giong song tnh mach.
Sieu am mau cho thay o nhay cao hn trong
viec cho thay dong chay tinh hoan giam trong xoan
khong hoan toan120 so vi chup xa hnh. Trong khi
sieu am Doppler mau hu dung trong anh gia ban
au cac trng hp nghi ng xoan tre em, nhap
nhay o ho tr dau hieu sieu am khi dong chay
trong tinh hoan khong xac nh c bang sieu am
mau.121 Cac tien bo gan ay trong viec phat hien
thieu mau tinh hoan la s dung sieu am Doppler
mode nang lng, giup gia tang kha nang phat hien
dong chay cham trong mach mau nho. Cac nghien
cu vi chat can quang trong mach mau dung trong
sieu am cho nhng ha hen gia tang o nhay trong
tam soat dong chay trong bu.
Trong trng hp xoan tinh hoan ban cap
hoac man, sieu am mau cho thay mat dong chay
trong tinh hoan va tang dong chay mo quanh tinh
hoan bao gom phc hp mao tinh-thng tinh va can
c bu (dartos)(Hnh 24-40). Trong trng hp
thao xoan, sieu am mau cho thay dong chay gia
tang trong va ngoai tinh hoan hoac dong chay bnh
thng.116,118 ieu quan trong phai nh la tang
tuan hoan phan ng cua tinh hoan do t khoi sau
nhng t xoan cach quang tao hnh anh giong
nh tang tuan hoan ang ke trong viem tinh hoan- Hnh 24-40. Thng tinh xoan ban cap do chan
mao tinh tren sieu am Doppler mau. Tuy nhien, thng cho thay khong co dong chay vi vung mo mem
cac dau hieu lam sang giup phan biet xoan tng phan ng tang tuan hoan (mui ten cong)
t va viem tinh hoan-mao tinh trong boi canh cap
tnh.
Xoan mau phu tinh hoan c mo ta nh Cac vi trung lay theo ng tnh duc gay viem
khoi phan am kem khong mach mau nam gan tinh nieu ao nh Gonococcus (lau cau) va Chlamydia
hoan ti mau bnh thng va bao quanh bi vung thng gap thanh nien. t gap hn, viem mao
tang ti mau tren sieu am Doppler mau.116 Tuy tinh co the xay ra sau quai b hoac viem tinh hoan
nhien, cac tac gia khac mo ta mot hnh anh khac, do giang mai. Tan suat cao tuoi 40 en 50. Kinh
o la khoi sinh am ngoai tinh hoan nam gia au ien, benh nhan co trieu chng khi phat au am
mao tinh va cc tren cua tinh hoan.122 tang dan sau 1 en 2 ngay. Sot, tieu kho, va chay
dch nieu ao co the gap.
Viem mao tinh va viem tinh hoan-mao tinh Sieu am cho thay mao tinh to day va thng
Viem mao tinh la nguyen nhan thng gap nhat xay ra vung au mao tinh (Hnh 24-41).13 50%
cua benh ly bu cap nam gii sau tuoi day th, trng hp anh hng toan bo mao tinh. o phan
chiem khoang 75% tat ca cac dien tien viem cap am cua mao tinh thng giam va cau truc phan am
trong tinh hoan. Nguyen nhan thng do nhiem thng tho va khong ong nhat, co le do phu ne
trung ng tieu di va lay theo ng mau hoac va/hoac xuat huyet. Tao dch tinh mac phan ng
chan thng th t hn. Vi trung thng gap la thng gap va day da bu thng thay.
Escherichia coli, Pseudomonas va Aerobacter.123 Sieu am Doppler mau thng cho thay gia tang
Hnh 24-41. Viem mao tinh cap. A, Khao sat cat doc benh nhan co viem mao tinh cap cho thay
au mao tinh to phan am kem (dau thap) va tran dch tinh mac phan ng lng t, H. T, tinh hoan. B,
Doppler nang lng cho thay dong chay tang (mui ten) trong au mao tinh to phan am kem, E. dong
chay trong tinh hoan khong tang, T.
Hnh 24-42. Viem tinh hoan mao tinh cap. Hnh 24-43. Viem tinh hoan mao tinh man ( khong
Doppler mau cho thay tang tn hieu tuan hoan, T. H, tran ap ng vi ieu tr ) . Tinh hoan khong ong nhat lan
dch tinh mac; E, mao tinh toa (dau thap) bao quanh bi mu tinh mac, P, co vach va
manh vun mu. Khi phau thuat, thay nhieu vung viem tinh
hoan va tao lap ap xe trong tinh hoan.
tuan hoan mao tinh va/hoac tinh hoan so vi ben ieu tr, toan bo tinh hoan co the b anh hng, to
khong trieu chng (xem Hnh 24-41).124 Viem lan ra va giam phan am (Hnh 24-43). Tinh hoan b
toa trc tiep ti tinh hoan goi la viem tinh hoan- anh hng cung co the do anh hng th phat cua
mao tinh, xay ra trong hn 20% cac trng hp viem mao tinh. oi khi, phu ne ro kem theo viem
viem mao tinh. Viem tinh hoan n oc co the mao tinh cap co the gay tac nghen tuan hoan cua
xay ra. Trong trng hp nay tang tuan hoan khu tinh hoan, tao ra thieu mau va he qua nhoi mau.
tru trong tinh hoan (Hnh 24-42). Tinh hoan b anh Neu giam tuan hoan tram trong tao ra nhoi mau
hng co the khu tru hoac lan toa. ac trng, tinh hoan toan bo, khong the phan biet cac thay
viem tinh hoan khu tru tao vung phan am kem oi nay vi xoan tinh hoan. Trong nhng trng
nam ke can vung mao tinh sng to. Neu khong hp nh vay, tang tuan hoan gan vung gay tac v
Bu 817
phu ne va sng to. Tang tuan hoan trong c bu

(dartos) va oan gan thng tinh co the noi bat so
vi thanh phan cua bu khong co tuan hoan nam xa
v tr tac. He qua thieu mau kem viem mao tinh co
the tao nguy c tinh hoan nhiem trung dang viem
tinh hoan khu tru, ap xe tinh hoan hoac viem tinh
hoan-mao tinh lan toa hoai th. Trong hau het
trng hp viem tinh hoan-mao tinh, tinh hoan van
gia b trn lang va hnh bau duc. Sieu am
Doppler mau co the cho thay nhng vung khu tru
tang tuan hoan phan ng va tang dong chay ket
hp vi nhng vung nhoi mau khong co mach mau
mao tinh lan tinh hoan oi vi nhng trng hp
viem tinh hoan-mao tinh nang. Dong chay ngc
tam trng trong song ong mach cua tinh hoan la
dau hieu xau lien quan ti nhoi mau tinh hoan
trong trng hp viem tinh hoan-mao tinh nang
CHAN THNG
Chan oan tc th v tinh hoan rat quan trong v

lien quan trc tiep gia can thiep phau thuat sm
va kha nang bao ton tinh hoan. Gan 90% tinh hoan E3
Hnh 24-44. Gay tinh hoan. Khao sat cat ngang thay
co the bao ton neu thc hien phau thuat trong vong tinh hoan khong ong nhat vi dai thang (mui ten) tng ng
72 gi au trong khi o ch con 45% sau 72 ng gay. H, khoi mau tu tinh hoan
gi.126,127 Thng khong the chan oan tren lam
sang v au va sng to bu. Jeffrey va cs.126 xac
nh chnh xac bang sieu am 12/12 trng hp v BENH LY BU CAP
tinh hoan. Tnh chat sieu am bao gom vung khu
tru bien oi phan am trong tinh hoan tng ng vi Xoan tinh hoan
vung xuat huyet hoac nhoi mau va tao khoi mau tu Viem tinh hoan-mao tinh cap
trong 33% benh nhan. Ch nhan ra mat v tiem an Xoan mau phu tinh hoan
trong 17% cac trng hp (Hnh 24-44). ng b Thoat v nghet
tinh hoan thng khong eu. Mac du nhng tnh Phu ne bu khong ro nguyen nhan
Chan thng
chat tren khong chuyen biet cho tinh hoan v,
Ban xuat huyet Henoch-Schonlein
chung co the gi y chan oan trong boi canh lam
sang phu hp, hng ti phau thuat tham do ngay
tc th. Sieu am Doppler mau co the cho thay s
giam tuan hoan (Hnh 24-45). Khao sat can than
e tranh lam lan vi khoi mau tu hon hp trong kham nghiem sau chan thng kn vung bu. Viem
tinh hoan. Sieu am Doppler mau co the giup tach mao tinh chan thng co the la dau hieu n oc
biet phan tinh hoan ti mau bnh thng vi khoi khong nen nham vi qua trnh nhiem trung.130
mau tu hon hp.128 Co the dung sieu am e nhan
nh tnh trang v tinh hoan nghiem trong do an TINH HOAN AN
ban. Co the phan biet cac khoi mau tu vi v tinh
hoan va co the nh v cac vat la trong tinh hoan.129 Bnh thng, tinh hoan bat au di chuyen xuong
Nen thc hien viec anh gia bang sieu am thang bu qua ong ben vao khoang tuan th 36 bao thai.
xam ky lng va sieu am Doppler mau trong moi Day chang bu la cau truc si-c trai t cc di
Hnh 24-46. Tinh hoan teo nam trong ong ben.

Khao sat cat doc qua ong ben cho thay tinh hoan an nho hnh
bau duc (mui ten) vi dai tang phan am tng ng vi trung
that tinh hoan (au mui ten)
hoan an: vo sinh va ung th. Vo sinh la hau qua

cua nhng thay oi benh hoc tien trien phat trien
trong ca tinh hoan an lan tinh hoan bnh thng oi
ben sau 1 tuoi.132-134 Tinh hoan khong xuong co
nguy c bien oi ac tnh gap 48 lan so vi tinh
hoan bnh thng.2 Ngi ta tin rang tnh trang
khiem khuyet hormone khien tinh hoan khong
xuong c tao nguy c ac tnh cho benh nhan.
Hnh 24-45. Phu tinh hoan va giam tuan hoan sau
chan thng khu tru. Khao sat Doppler mau qua cc Hang nam, khoang 0.04% benh nhan co mot tinh
di tinh hoan b chan thng (mui ten) khong thay mach hoan khong xuong se phat trien thanh ung th.
mau. Nguy c t vong do benh ly ac tnh cua tinh hoan
an ong bat ky tuoi nao co mot tinh hoan khong
tinh hoan en bu va hng dan tinh hoan trong lo xuong cao gap 9.7 lan so vi ngi bnh thng.133
trnh i xuong, bnh thng hoan tat vao luc sinh Benh ly ac tnh thng gap nhat la seminoma.
ra.9 Tinh hoan khong xuong la mot trong nhng d Nguy c ac tnh eu gia tang tinh hoan khong
tat nieu-duc thng gap nhat be trai. Vao luc xuong sau khi a phau thuat lan tinh hoan xuong
sanh, 3,5% be trai nang hn 2500 g co mot tinh bnh thng. V the, nhat thiet phai kham nh ky
hoan khong xuong; 10% en 25% trng hp nay ca hai tinh hoan.
xay ra hai ben. Con so nay giam ti 0,8% khoang Do v tr nong trong ong ben cua tre em, nen
1 nam tuoi do tinh hoan xuong t nhien trong hau thc hien sieu am tm tinh hoan khong xuong vi
het tre s sinh. Tan suat cua tinh hoan khong au do tan so cao va em nc nham tranh cac
xuong tang ti 30% tre sinh non, chiem gan anh gia a am phan hoi. Ve mat sieu am, Tinh
100% tre s sinh nang di 1000 g vao luc hoan khong xuong thng nho hn va giam nhe
sinh.131,132 Viec tinh hoan xuong hoan toan la can phan am so vi tinh hoan oi ben xuong bnh
thiet e tinh hoan trng thanh ay u.131,132 thng (Hnh 24-46). Co the chan oan chuyen
Tinh hoan v tr bat thng co the nam bat c biet tinh hoan khong xuong khi nhan ra trung that
ni nao doc lo trnh i xuong t khoang sau phuc tinh hoan. Co the nham mot hach lympho ln hoac
mac ti bu. Phan ln (80%) cac tinh hoan khong phan di tinh mac cua day chang bu (pars
xuong co the s c nam ngang hoac ben di infravaginalis gubernaculum testis = PIG), tc phan
mc ong ben. Khong co tinh hoan chiem 4% benh phnh len pha xa cua day chang bu vi mot tinh
nhan khong s thay tinh hoan.132 hoan nhng tren ly thuyet, cac cau truc trc
nh v tinh hoan khong xuong rat quan trong khong mang mot dai tang am. Hn na, co the thay
e ngan nga hai bien chng tiem an cua tinh nhng o tang am ben trong PIG va hach khien
Bu 819
chan oan nham la tinh hoan khong xuong. Tren 5. Rifkin MD, Kurtz AB, Pasto ME et al. The sonographic diagnosis
of focal and infiltrating intrascrotal lesions. Urol Radiol 1984; 6:
thc te, khong phai de nhan ra trung that tinh hoan 20 - 26.
cua tinh hoan khong xuong. Sau khi hoan tat viec 6. Rifkin MD. Scrotal ultrasound. Urol Radiol 1987; 9: 119 - 126.
7. Middleton WD, Bell MW. Analysis of intratesticular arterial
i xuong, PIG va day chang bu thng teo i. Neu
anatomy with emphasis on transmediastinal arteries. Radiology
tinh hoan van khong xuong, hai cau truc se van ton 1993: 189: 157 - 160.
tai. PIG nam xa hn tinh hoan khong xuong, Giai phau hoc
thng trong bu nhng cung co the tm thay trong 8. Trainer TD. Histology of the normal testis. Am J Surg Pathol
1987; 11: 797 - 809.
ong ben. Tren sieu am, PIG la mot cau truc nh si
9. Rifkin MD. Fov PM, Goldberg BB. Scrotal ultrasound: acoustic
thng, phan am kem, tng t nh tinh hoan, vi characteristics of the normal testis and epididyrnis defined with
day chang noi lien nhau.135 high resolution superficial scanners. Mod Ultrasound 1984: 8: 91 -
97.
Mc o thanh cong cua sieu am trong viec 10. Alien TD. Disorders of the male external genitalia. In: Kelalis
nh v cac tinh hoan khong xuong thay oi tuy PP. King LR, eds. Clinical Pediatric Urology, Philadelphia: WB
theo nghien cu. Wolverson va cs.136 bao cao o Saunders Co; 1976: 636 - 668.
11. Faklirv J, Khoury A, Barakat K. The hypoechoic band: a normal
nhay 88%, ac hieu 100% va o chnh xac 91%. finding on testicular sonography. AJR 1989; 153: 321 - 323.
Mot nghien cu sau nay, Weiss va cs.137 bao cao 12. Gooding GAW. Sonography of the spermatic cord. AJR 1988;
151: 721 - 724.
o nhay 97% oi vi tinh hoan s thay va 13% vi
tinh hoan khong s thay. MRI co o nhay va o Khoi u bu
13. Benson CB, Doubilet PM, Richie JP. Sonography of the male
chuyen biet tng t nh sieu am trong viec anh genital tract. A. JR 1989; 53: 705 - 713.
gia tinh hoan an.138,139 MRI chia xe hai li iem 14. Rifkin MD, Kurtz AB, Pasto ME et al. Diagnostic capabilities of
high - resolution scrotal ultrasonography: prospective evaluation.
chnh vi sieu am: khong xam lan va khong nhiem Ultrasound Med 1985; 4: 13 - 19.
xa. Mot li iem khac na cua MRI la kha nang 15. Grantham JG, Charboneau JW, James EM et al. Testicular
thu c nhng hnh anh a mat phang cua khoang neoplasms: 29 tumors studied by high - resolution ultrasound.
Radiology 1985; 775 - 780.
sau phuc mac va vung ben. ac trng, tinh hoan 16. Kirschling RJ, Kvols LK, Charboneau JW et al. High - resolution
khong xuong co tn hieu giam so vi m trong ultrasonographic and pathologic abnormalities of germ cell
chuoi TR/TE ngan va tang tn hieu hoac ong tn tumors in patients with clinically normal testes. Mayo Clin Proc
1983: 58: 648 - 653.
hieu so vi m tren chuoi TR/TE dai. Nhng ac 17. Javadpour N. Principles and Management of Testicular Cancer.
tnh ve tn hieu nay cua tinh hoan khong xuong New York: Thieme Inc; 1986.
18. Goldfinger SS, Rothberg R, Buckspan MB et al. Incidental
cung giong nh cua tinh hoan nam trong bu. Yeu detection of impalpable testicular neoplasm by sonography. AJR
iem cua MRI la gia cao, thi gian thc hien dai, 1986; 146: 349 - 350.
thng ch cho an than va khong the dung chat 19. Talerman A, Roth LM. Pathology of the Testis and Its Adnexa.
New York: Churchill Livingstone: 1986.
tng phan trong ai trang khi anh gia cac tinh 20. Jacobsen GK, Talerman A. Atlas of Germ Cell Tumors.
hoan trong o bung. Do gia thap, thc hien nhanh, Copenhagen: Munksgaard; 1989.
khong nhiem xa, khong can dung chat tng phan 21. Ruzal - Shapiro C, Newhouse JH. Genitourinary ultrasound. In:
Taveras JM, Ferrucci JT, eds. Radiology: Diagnosis - Imaging
uong, khong can ti thuoc an than, nen sieu am la Intervention. Philadelphia: JB Lippincott Co; 1986: 4.
phng phap anh gia au tien oi vi tinh hoan 22. Schwerk WB, Schwerk WNM, Rodeck G. Testicular tumors:
prospective analysis of real - time ultrasound patterns and
an. Khong thay c tinh hoan khong xuong bang abdominal staging. ' Radiology 1987: 164: 369 - 374.
sieu am hoac MRI cung khong loai tr s hien 23. Mostofi FK, Price EB Jr. Tumors of the male genital system. In:
dien cua no va v the, nen thc hien noi soi o bung Atlas of Tumor Pathology, Fascicle 8, 2nd series. Washington,
DC: Armed Forces Institute of Pathology; 1973.
hoac phau thuat tham sat mot khi co ch nh cua 24. Emory TH, Charboneau JW, Randall RV et al. Occult testicular
lam sang. interstitial - cell tumor in a patient with gynecomastia: ultrasonic
detection. Radiology^ 1984; 151: 474.
25. Cunningham JJ. Echographic findings in Sertoli cell tumor of the
THAM KHAO testis. Clin Ultrasound 1981; 9: 341 - 342.
26. Glazer HS, Lee JKT, Melson GL et al. Sonographic detection of
1. Can - oil BA, Gross DM. High - frequency scrotal sonography.
occult testicular neoplasms. AJR 1981; 138: 673 - 675.
A/7 1983; 140: 511 - 515.
27. Bockrath JJ, Schaeffer AJ, Kies JS et al. Ultrasound identification
2. Krone KD, Carroll BA. Scrotal ultrasound. Radiol din North Am
of impalpable testicular tumor. Urol 1981: 130: 355 - 356.
1985; 23: 121 - 139.
28. Moudy PC, Makhija JS. Ultrasonic demonstration of a non -
3. Middleton WD. Thorne DA, Melson GL. Color Doppler ultra -
palpable testicular tumor. Clin Ultrasound 1983: 11: 54 - 55.
sound of the normal testis. AJR 1989; 52: 293 - 297.
29. Shawker TH, Javadpour N. VLeary T, et al: Ultrasono - graphic
4. Hricak H, Filly RA. Sonography of the scrotum. Invest Radiol
detection of "burned - out" primary testicular germ cell tumors in
1983; 18: 112 - 121.
clinically normal testes. Ultrasound Mod 1983; 2: 477 - 479.
30. Horstman WG, Melson GL, Middleton WD et al. Testicular 57. Older RA, Watson LR. Tubular ectasia of the rete testis: a benign
tumors: findings witli color Doppler LS. Radiology - 1992: 185: condition with a sonographic appearance tliat may he
733 - 737. misinterpreted as malignant. J Urol 1994: 152: 477 - 478.
31. Luker GD, Sicgel MJ. Pediatric testicular tumors: evaluation with 58. Cho CS, Kosek , 1. Cystic dysplasia of the testis: sonographic and
gray - scale and color Doppler US. Radiology - 1994: 191: 561 - pathologic findings. Radiology - 1985; 156: 777 - 778.
564. 59. Keetch D\V, McAlistcr WH, Manlev CB el al. Cystic dysplasia of
32. Horstman WG, Haluszka MM, Burkhard TK. Management of the testissonographic features with pathologic correlation.
testicular masses incidentally discovered by ultrasound. LW Pediatr Radial 1991: 21: 501 - 503.
1994: 151: 1263 - 1265. 60. Shah KTI, Maxted WC, Dhun B. Epidermoid cysts of the teslis: a
33. Doll DC, Weiss RB. Malignant lyinphoma of the testis. Am J report of three cases and an analysis of 141 cases from the world
Mod 1986: 81: 515 - 523. literature. Cancer 1981: 47: 577 - 582.
34. Tepperman BS, Gospodarowicz M, Bush RS et al. Non - Hodgkin 61. Caravelli JP, Peters BE. Sonography of bilateral testicular
Ivmphoma of the testis. Radiology - 1982: 142: 203 - 208. epidermoid cysts. Ultrasound Med 1984; 3: 273 - 274.
35. Paladugu RP, Beannan RM, Rappaport H. Malignant lyin - 62. Buckspan MB, Skeldon SC. Klolz PC et al. Epidermoid cysts of
phoma with primary manifestation in the gonad: a clinico - the testicle. Urol 1985: 134: 960 - 961.
pathologic study of 38 patients. Cancer 1980: 45: 561 - 571. 63. Maiek RS. Rosen . IS, Earrow - CM. Epidermoid cyst of the
36. Hamlin JA, Kagan AR, Friedman NB. Lymphomas of the testicle. lestis: a critical analysis. BrJ. Irol 1986: 58: 55 - 59.
Cancer 1972: 29: 1532 - 1536. 64. Eisenmenger M, Lang S, Donner CII et al. Epidermoid cysts of
37. Ravor RA, Schcible W, Brock WA et al. High resolution the testis: organ - preserving surgery followdng diagnosis by
ultrasonographv in the diagnosis of testicular relapse iu patients ultrasonography. Br. Urol 1993: 71: 955 - 957.
with lymphoblastic leukemia. J Urol 1982: 128: 602 - 603. 65. 1 lermansen . 1C, Dhusid M. f, Sty MR. Bacterial epididymo -
38. Phillips G, Kumari - Subaiya S, Sawilsky A. Ultrasonic orchitis in children and adolescents. Clin Pediatr 1980: 19: 812 -
evaluation of the scrotum in lymphoproliferative disease. 815.
Ultrasound Mod 1987: 6: 169 - 175. 66. Mevoracli RA. Eerner RM, Dvoretsky PM et al. Testicular
39. Mazzu D, Jeffrey RB Jr, Rails PW. Eymphoma and leukemia abscess: diagnosis by ultrasonography. Urol 1986: 136: 1213 -
involving the testicles: findings on gray - scale and color Doppler 1216.
sonography. AJR 1995: 164: 645 - 647. 67. Korn RE, Langer JE, Nisenbaum HL et al. Non - Hodgkin's
40. Dahnert WE, Rifkin MD, Kurtz AR. Ultrasound case of the day. Ivmphoma mimicking a scrotal abscess in a patient with AIDS. J
RadioGrapldcs 1989; 9: 554 - 558. Ultrasound Med 1994; 13: 715 - 718.
41. Crignon D. I, Shuni DT, IIayman WP. Metastatic tumors of the 68. Smith FJ, Bilbey JH, Filipenko JD et al. Tcsticular pseudo - tumor
testes. CanJSurg 1986: 29: 359 - 361. in the acquired immunodeficiency syndrome. Urology 1995; 45:
42. Werth V. Yii G, Marshall FF. Nonlymphomatous metastatic 535 - 537.
Kimor to the testis. Urol 1981: 127: 142 - 144. 69. Vick GW, Bird LI, Rosenfield AT et al. Scrotal masses with a
43. Flanash KA. Carncy JA, Kelalis PP. Metastatic tumors to uniformly hyperechoic pattern. Radiology - 1983; 148: 209 21.
testicles: routes of metastasis. Urol 1969: 102: 465 - 468. 70. Blei I. , Sihelnik S, Bloom D et al. llltrasonographic analysis of
44. Hanim B, Fobbe F, Loy V. Testicular cysts: diffcrentialion with chronic intratesticular pathology. Ultrasound Med 1983: 2: f 7 -
ultrasound and clinical findings. Radiology 1988: 168: 19 - 23. 23.
45. coding GAW. Leonhardt W, Stein R. Testicular cysts: US 71. Wu VH, Dangman BG, Kaufman RP, |r. Sonograpllic appearance
findings. Radiology 1987; 163: 537 - 538. of acute Testicular venous infarction in a patient witli a
46. Recker J, Arger PH. Wein AJ et al. Inclusion cyst of the tunica hvpercoagulable state. J Ultrasound Med 1995; 14: 57 - 59.
albuginea: demonstration by ultrasound. Urol Radial 1983: 5: 127 72. Elanagan JJ, Fowler HG. Testicular infarction niimicking tumour
- 129. on scrotal ultrasounda polential pitfall. Clin Radio! 1995: 50:
47. Turner WR, Derrick KC, Sanders P et al. Benign lesions of the 49 - 50.
tunica albuginea. J lirol 1977: 117: 602 - 604. 73. Einstein DM. Paushter DM. Singer AA et al. Eibrotic lesions of
48. Warner KE, Noyes DT, Ross JS. Cysts of the tunica albugiuea the testicle: sonographic patterns mimicking malignancy. I'rol
testis: a report of 3 cases with a review of the literature. Urol Radial 1992; 14: 205 - 210.
1984: 132: 131 - 132. 74. Rifkin MD, Kurtz AB. Coldberg BB. Fpididymis exaniined hv
49. Poster BB, Spirt BA, Tamsen A et al. Complex tunica albuginea ultrasound: correlation with pathology. Radiology - 1984: 151:
cyst simulating an intratesticular lesion. Ural Radiol 1991: 13: 187 - 190.
129 - 132. 75. Avila NA. Premkumar A, Shawker TH el al. Teslicular adrenal
50. Takihari H. Valvo JR, Tokuhara M ct al. Intratesticular cysts. rest tissue in congenital adrenal hyperplasia: findings al gray -
Urology 1982: 20: 80 - 82. scale and color Doppler US. Radiology - 1996; 198: 99 - 104.
51. Rifkin MD. Jacobs JA. Simple testicular cyst diagnosed 76. Vanzulli A, DelVIaschio A, Paesano P el al. Testicular masses in
preoperalively by ultrasound. Ural 1983: 129: 982 - 983. association with adrenogenital syndrome: US findings. Radiology
52. Fisher JE. Jewett TC, Nelson SJ et al. Ectasia of the rate teslis - 1992; 183: 425 - 429.
witli ipsilateral renal agenesis. J Urol 1982: 128: 1040 - 1043. 77. Gierkc CL, King BE, Bostwick DC el al. Large - cell calcifying
53. Nistal M, Regadcra J, Paniagua R. Cystic dysplasia of the testis. Sertoli cell tumor of the testis: appearance al sonography. AJH
Arch. Pathol Lab Med 1984: 104: 579 - 583. 1994: 163: 373 - 375.
54. Tartar VM, Trambert MA, Balsara ZN et al. Tubular ectasia of 78. Doherlv F. I, Mullins TL. Sant GR et al. Testicular microlithiasis:
the testicle: sonographic and MR imaging appearance. A. IR a unique sonographic appearance. [lltrasound Med 1987: 6: 389 -
1993: 160: 539 - 542. 392.
55. Brown DL. Benson CB, Doherty F. I el al. Cystic testicular mass 79. Nistal M, Paniagua R, Dicz - Pardo JA. Testicular microlithiasis
caused by dilated rcte testis: sonographic findings in 31 cases. in 2 children with bilateral crypt orchidism. J Urol 1979: 121: 535
AIR 1992: 158: 1257 - 1259. - 537.
56. Weiiigarten B. I, Kelhnan CM Middleton WD et al. Tubular 80. Vegni - Talluri M, Bigliardi E, Vanui MG el al. Testicular
ectasia within the mediastinum teslis. Ultrasound Med 1992: 11: microliths: their origin and structure. Urol 1980; 124: 105 - 107.
349 - 353. 81. Breger RG, Passarge E. McAdams AJ. Testicular intratubular
Bu 821
bodies. J din Endocrinol Metah 1965; 25: 1340 - 1346. 107. Clien DCP, Holder LE, Kaplan GN. Correlation of radionu - clide
82. Janzen DJ. Mathieson JR. Marcli JI et al. Testicular imaging and diagnostic ultrasound in scrotal diseases. Nucl Mod
microlithiasis: sonographic and clinical features. AJR 1992: 108: 1986: 27: 1774 - 1781.
1057 - 1060. 108. Williamson RON. Torsion of the testis and allied conditions.
83. Backus ML. Mack AT, Middleton WD et al. Testicular BrJSurg 1976; 63: 465 - 476.
microlithiasis: imaging appearances and pathologic correlation. 109. Einkelstein MS, Roscnbcrg HK, Snyder HM et al. Ultrasound
Radioloy - 1994: 192: 781 - 785. evaluation of scrotum in pediatrics. Urology - 1986: 27: 1 - 9.
84. Patel MD, Olcott RW. Kerschmann RL et al. Sonographically 110. Bird K, Rosenfield Al, Taylor KJW. Litrasonographv in testicular
detected tcsticular microlitliiasis and teslicular carcinoma. Clin torsion. Radiology 1983: 147: 527 - 534.
Ultrasound 1993; 21: 447 - 452. 111. Middleton WD, Melson GL. Testicular ischemia: color Dopplcr
85. Linkowski GD, Ayelloiio A, Gooding GAW. Scrotal calculi: sonographic findings in five patients. A. JR 1989: 152: 1237 -
sonographic detection. Radiolog) - 1985; 156: 484. 1239.
86. Lenng MI. ooding GAW, Williams RD. High - resolution 112. Chinn DH, Miller ET. Generalized testicular hvpere - chogenicitv
sonographv of scrotal contents in asymptomatic subjects. AJH in acute testicular torsion. Ultrasound Me. d 1985: 4: 495 - 496.
1984: 143: 161 - 164. 113. Vick JW, Bird K, Rosenfield AT et al. Extratesticular hemor -
87. Worthy L, Miller El, Chin DII. Evaluation of extratesticular rhage associated with torsion of the spermatic cord: sono -
findings in scrotal neoplasms. Ultrasound Med 1986: 5: 261 - 263. graphic demonstration. Radiology 1986: 158: 401 - 404.
88. Gunningham JJ. Sonographic findings in clinically unsuspected 114. Bird K, Rosenfield AT. Testicular infarction secondary to acute
acute and chronic scrotal hemaloceles. MR 1983: 140: 749 - 752. inflammatory disease: demonstration bv B - scan ultra - sound.
89. Wolverson MK, Houtluin E, Heiberg E et al. High - resolution Radiology - 1984; 152: 785 - 788.
real - time sonography of scrotal varicocele. AJR 1983; 141: 775 - 115. Margin B, Conte J. Ultrasonographv of the acute scrotum. din
779. Ultrasound 1987; 15: 37 - 44.
90. Belker AM. The varicocele and male infertility. Urol Clin North 116. Eerner RM, Mevorach RA. Hulbert WC et al. Color Doppler
Am 1981: 8: 41 - 44. ultrasound in the evaluation of acute scrotal disease. Radiolosx -
91. Gonda RE, Karo JJ, Eorte RA et al. Diagnosis of subclinical 1990: 176: 355 - 358.
varicocele in infertility. A. IR 1987: 148: 71 - 75. 117. Burks DD, Markey BJ, Burkhard TK et al. Suspected testicular
92. Hamm G, Fobbe F, Sorensen R et al. Varicoceles: combined torsion and ischemia: evaluation with color Doppler sonography.
sonography and thermography in diagnosis and post - thera - Radiology 1990; 175: 815 - 821.
peutic intervention. Radiology 1986: 160: 419 - 424. 118. Middleton WD, Siegel BA, Melson GE et al. Acute scrotal
93. McClnre RD, Hricak H. Scrotal ultrasound in the infertile man: disorders: prospective comparison of color Doppler US and
detection of subclinical unilateral and bilateral varicoceles. Urol testicular scintigraphy. Radiology 1990: 177: 177 - 181.
1986; 135: 711 - 714. 119. Bude RO, Kennelly MJ, Adier RS et al. Nonpulsatile arterial
94. Subramanyam BR, Balthazar EJ, Raghavendra BN et al. aveforms: observations during graded testicular torsion in rats.
Sonographic diagnosis of scrolal hernia. AJR 1982: 139: 535 - AcadRadiol 1995; 2: 879 - 882.
538. 120. Fitzgerald SW, Erickson S, DeWire DM et al. Color Doppler
95. Favsal MH, Strefling A, Kosek JC. Epididvmal neoplasms: a case sonographv in the evaluation of the adult acute scrotum.
reporl and review. J Urol 1983: 129: 843 - 844. Ultrasound Mod 1992: 11: 543 - 548.
96. Pavone - Macaluso M, Smith PH. Bagshavv MA. Testicular 121. Atkinson Jr GO. Patrick I. E. Ball TI Jr et al. The normal and
Cancer and Other Tumors of the Genitourinaly Tract. New York: abnormal scrotum in children: evaluation with color Doppler
Plenum Press; 1985. sonography. AJR 1992: 158: 613 - 617.
97. Smallman LA, Odedra JK. Primary carcinoma of sigmoid colon 122. Hesser U, Rosenberg M. Gierup . 1 el al. Cray - scale
metastasizing to epididvmis. Urology' 1984: 23: 598 - 599. sonograpliv in torsion of the testicular appendages. Pediair Radial
98. Wachtel TE, Mchan DJ. Melaslalic tumors of the epididvmis. 1993: 23: 529 - 532.
JUrol 1970: 103: 624 - 626. 123. Berger RE, Alexander P^R. Harnisch JP et al. Etiology, mani -
99. Durmer PS, Lipsit ER. Nochomovitz I. E. Epididvmal sperm festations and therapy of acute epididymhis: prospective study of
gramiloma simulating a testicular neoplasm. J din Ultrasound 50 cases. Urol 1979: 121: 750 - 754.
1982: 10: 353 - 355. 124. Horslman \VC, Middleton WD. Melson GE. Scrotal inflam -
100. Ramanalhan K, Yaghoobian J, Pinck RE. Sperm granulorna. din matory disease: color Doppler US findings. Radi olog\' 1991; 179:
Ultrasound 1986: 14: 155 - 156. 55 - 59.
101. Jarvis L. I, Dubbins PA. Changes in the epididvmis after 125. Sanders EM, Haber S, Dembner A et al. Significance of reversal
vaseclotnv: sonographic findings. AJR 1989: 152: 531 - 534. of diastolic flow in the acute scrotum. Ultrasound AW1994; 13:
102. Eflekhari F, Smith JK. Sonographv of the scrotum after or - 137 - 139.
chieclomv: iiormal and abnormal findings. A. IR 1993: 160: 543 -
Chan thng
547.
126. Jeffrey RB. Eaing FC. Hricak H el al. Sonography of teslicular
103. Fowler RG, Chennells PM, Ewing R. Scrotal ultrasonography: a
trauma. AJR 1983: 141: 993 - 995.
clinical evaluation. BrJ Radiol 1987: 60: 649 - 654.
127. Eupetin AR, King W, Rich PJ et al. The traumatized scrotum:
Benh ly bu cap ultrasound evaluation. Radiology 1983: 148: 203 - 207.
104. Mueller DE, Amundson CM, Rnbin SZ et al. Acute scrotal 128. Cohcn HE, Shapiro ME. Haller . 10 et al. Sonography of
abnormalities in children: diagnosis by combined sonography and iutrascrotal hematomas simulating testicular rupture in
scintigraphy. AJR 1988: 150: 643 - 646. adolescents. Pediatr Radiol 1992; 22: 296 - 297.
105. Hricak H, Lue T, Fillv RA et al. Experimental study of the 129. Eearch TJ, Hansch EP, Rails PW. Sonography in patients with
sonographic diagnosis of testicular torsion. J Ultrasound Mod gunshot wounds of the scrotum: imaging findings and their value.
1983: 2: 349 - 356. AIR 1995; 165: 879 - 883.
106. Donahue RE, Cass BP, Veeraraghavan K. Immediate exploration 130. Cordon EM. Stein SM, Rails P\V. Traumatic epididymitis:
of the unilateral acute scrotum in young male subjects. JUrol evaluation with color Doppler sonography. AJR 1996: 166: 1323 -
1978: 124: 829 - 832. 1325.
Tinh hoan an 136. Wolverson MK, Elouttuin E, Heiberg E et al. Comparison of

131. Elder JS. Cryptorchidism: isolated and associated with oilier computed tomography with high - resolution real - time ultra -
genitourinary defects. Pediatr din Nortli Am 1987: 34: 1033 - sound in the localization of llie impalpable undescended testis.
1053. Radiology 1983: 146: 133 - 136.
132. Harrison JH et al. CairipbelFs Urology. - Hh ed. Philadelphia: 137. Weiss R, Carter AR, Rosenfield AT. High - resolution real - time
WB Saunders Co; 1979. ultrasound in the localization of the undescended testis. J Urol
133. Friedland CW. Chang P. The role of imaging in the management 1986; 135: 936 - 938.
of the impalpable undescendcd tcstis.\JR 1988: 151: 1107 - 1111. 138. Fritzsche PJ, Hricak H, Kogan BA et al. Undescended testis:
134. Kogan SJ. Crvptorchidism and infertility: an overview. Dialog value of magnetic resonance imaging. Radiolog)' 1987: 169 - 173.
Pediatr Urol 1982: 4: 2 - 3. 139. Kier R, McCarthy S, Rosenfield AT et al. Noiipalpable testes in
135. Rosenfield AT, Blair DN. McCarthy S et al. Tlie pars young boys: evaluation with magnetic resonance imaging.
infravaginalis gubernaculi: importance in the identification of tlie Radiology - 1988; 169: 429 - 433.
undescendcd tcstis. AJR 1989: 153: 775 - 778.
C H N G 2 5
Dng vat

Bernard F. King, Jr., M.D.
D A N B A I chi tiet ve cau truc giai phau hoc va mach mau cua
dng vat. Tnh thong dung va khong gay nhiem
GIAI PHAU HOC xa lam cho sieu am tr thanh mot trong cac phng
SINH LY tien ha hen trong viec anh gia benh ly dng
KY THUAT KHAO SAT vat.
BAT LC Sieu am co gia tr trong anh gia khoi u, chan
Cac khao sat khong xam lan va xam lan thng va hep nieu ao dng vat. Benh
Khao sat Doppler duplex Peyronie va bat thng bam sinh cua dng vat co
Bat lc do nguyen nhan ong mach the khao sat tot bang sieu am vi o phan giai cao.
Bat lc do nguyen nhan tnh mach S phat trien trien vong nhat trong sieu am
Khao sat Doppler duplex ong mach hang dng vat la trong anh gia bat lc. Khong ch
ngi bnh thng anh gia bang sieu am thang xam ma con sieu am
Cac bay trong sieu am Doppler duplex Doppler cac ong mach dng vat. Cac thong tin
trong benh bat lc giai phau va anh gia tuan hoan co the giup chan
BENH PEYRONIE oan benh nhan b bat lc do nguyen nhan mach
NIEU AO DNG VAT mau.
CARCINOMA DNG VAT
CHAN THNG DNG VAT GIAI PHAU HOC
Giai phau cua dng vat phc tap nhng thong

nhat (Hnh 25-1). Dng vat bao gom ba cau truc
Dng vat la c quan sinh duc nam; no co chc dang ong cua mo hang. Hai the hang nam trong
nang kep la cng len va la ng bai tiet nc hai phan ba pha trc (lng) dng vat va mot the
tieu va tinh dch. Trong qua kh, khao sat hnh xop duy nhat chiem 1/3 pha sau (long) cua dng
anh dng vat ch gii han tren phim thng, chup vat. Hai the hang la cau truc chnh gay cng cng
ng nieu va chup the hang. Chup cat lp ien dng vat. Ca ba the nay c bao boc bi lp can
toan (CT) hoac cong hng t (MRI) a c e day, tunica albuginea (lp bao trang). Nieu ao
xuat nh la phng tien co gia tr trong anh gia chay doc trung tam cua the xop. pha xa,
benh ly dng vat.1-3 Tuy nhien, gan ay sieu am dng vat co cc hnh non, la qui au dng vat.
dng vat vi o phan giai cao kem sieu am Qui au dng vat tao t cho phnh to cua the xop
Doppler mach mau dng vat cung cap thong tin bao phu au tan cua hai the hang. The hang va
HNH 28-1. Hnh ve cat ngang cua giai phau dng vat. (Theo Quam JP, King BF, James
Em va cs. Duplex and color Doppler sonographic evaluation of vascular impotence. AJR 1989: 153:
1141-1147.). tm=tnh mach. m=ong mach
the xop bao gom cac xoang lot bi c trn va noi chay doc gan trung tam moi the hang, cho cac
mo. Co mot vach chia hai the hang cha nhieu ca nhanh xoan nho noi trc tiep vi cac xoang ma
so cho phep cac kenh thong noi cac xoang cua hai khong thay tren sieu am. Cap ong mach lng
the hang. Cac xoang nho nay trong the hang gian dng vat cung cap mau chu yeu cho da va qui
to cha ay mau trong khi cng. The xop cung to au dng vat. Tuy nhien, co cac nhanh noi gia
ra khi cng nhng gop phan khong ang ke trong ong mach lng va ong mach hang sau.
tnh trang cng cng cua dng vat. Dan lu tnh mach cua mo cng dng vat
Mau cung cap cho dng vat chu yeu t ong chu yeu la tnh mach nho lien lac ma khong the
mach then trong trai va phai, bat nguon t ong thay tren sieu am. Cac tnh mach nay xuyen
mach chau trong trai va phai. Moi ong mach then tunica albuginea day va o vao tnh mach mu va
trong cho nhanh tang sinh mon, nhanh hanh dng chay doc theo mat lng dng vat va o vao tnh
vat (bulbar) va mot nhanh ong mach nieu ao rat mach lng sau dng vat, thay c tren sieu am
nho trc khi tr thanh ong mach dng vat. (Hnh 25-3). Tnh mach lng sau o vao am roi
ong mach dng vat trai va phai chay vao goc tnh mach sau xng mu. Dan lu tnh mach cua
dng vat va cho nhanh ong mach dng vat hang the hang cung theo tnh mach goc tai goc dng
va ong mach lng dng vat. Cac ong mach vat. Da va quy au dng vat c dan lu theo
hang la nguon cung cap mau chnh cho mo cng cac tnh mach lng nong.
cua dng vat (Hnh 25-2). Moi ong mach hang
Dng vat 825
Hnh 25-2. The hang. A, Sieu am cat ngang cua dng vat cho thay the hang trai (L) va phai (R). Cac ong
mach hang (mui ten) thay gan ng gia cua moi the hang. B, Sieu am Doppler mau cho thay cac ong mach hang
nay ro hn.
mach e duy tr s gian to cac xoang va lam giam

dong chay tnh mach t cac xoang (Hnh 25-4).
Vi dong chay ong mach lien tuc va giam dan lu
tnh mach, cac xoang gian to ti mc cac mo the
hang tr nen cng.4-15.
Cac hoat chat lam gian xoang cha c ro.
Hoat chat giao cam adrenergic c che gian c trn
cua xoang trong trang thai dng vat mem c ban.
Khi co kch thch cng cng do tam ly, cac au
tan cua than kinh pho giao cam c kch hoat bi
acetylcholine. Cac tac dung pho giao cam cholin-
Hnh 25-3. Tnh mach lng. Doppler mau cat doc mat ergic nay c che si giao cam adrenergic; do vay
lng dng vat cho thay tnh mach lng dng vat dep (mui ten cho phep th gian c trn. Hn na, acetylcholine
en) dan lu mau t mo cng dng vat. Tnh mach lng nong gian tiep kch thch te bao noi mo lot trong cac
dng vat (mui ten trang) dan lu mau t da va au dng vat. xoang. Tac dung cholinergic nay tren te bao noi
mo tao ra yeu to gay gian dan xuat t noi mo
SINH LY HOC (Endotheliem-derived relaxing factor = EDRF),
va ngi ta cho rang chat nay lam gian c trn lot
Cng dng vat do gian c trn thanh cua cac trong cac xoang qua chat nitrous oxide.16,17 Khi
xoang, ong mach xoan va ong mach hang cua khong con cac kch thch tam ly gay cng, gian c
moi the hang. Khi trng lc c xoang giam va trn va gian cac mach mau dng vat giam. Cac
cac xoang gian cha ay mau, cac tnh mach lien xoang teo nho t gay e ep len tnh mach lien lac
lac b ep gia cac xoang ngoai bien va lp trang. va cho phep dong chay tnh mach thoat ra. Dng
Qua trnh nay kch hoat c che lam tac nghen tnh vat tr nen mem.18,19
Hnh 25-4. The hang trang thai mem va cng. Hnh ve cat ngang cua the
hang trang thai mem (A) va cng (B). Trong qua trnh cng, ong mach hang va cac
xoang (S) gian cha mau va chen ep cac tieu tnh mach len lp trang (tunica albuginea)
cng day (TA). S chen ep cac tnh mach gan nh hoan toan ngan khong mau tnh mach
thoat khoi mo the hang va cho phep tnh trang gian cc ai keo dai cua xoang the hang,
tao s cng cng. tm=tnh mach. m.=ong mach
Dng vat 827
KY THUAT KHAO SAT cac lp quanh cac the. Cac bat thng s nan c
nh mang Peyronie) nen c khao sat anh gia
Khao sat sieu am dng vat vi t the benh nhan cac tnh chat sieu am cua cac khoi va v tr chnh
nam nga, dng vat nam tren thanh bung trc xac cua chung so vi cac the.
(Hnh 25-5). au do linear array tan so cao (7,5 anh gia cac the cua dng vat c thc hien
en 10 MHz) cho hnh anh dng vat vi o phan t mat long cua dng vat. Thay cac ong mach
giai cao. au do at ngang tren mat long dng hang di dang nhng cau truc nho dang ong,
vat bat au t au dng vat di chuyen xuong goc thanh tang am, nam trung tam the hang. anh
dng vat. De dang nhan ra hai the hang tren mat gia the xop va nieu ao cung c thc hien t
cat ngang la cau truc tron nam sat nhau ngan cach mat lkong dng vat. Co the s dung mot lng gel
nhau bi vach dng vat. Cac ong mach hang va u hoac mieng em am at tren be mat dng
thay gan phan gia cua the hang (Hnh 25-2). vat co the lam hien ro va tranh hien tng chen
Hiem khi thay cac mach mau bang he bat ngang ep dng vat do au do. Hnh anh nieu ao dng
vach dng vat t ong mach hang nay ti ong vat thay ro khi no gian. ieu nay c thc hien
mach hang kia hoac t ong mach lng dng vat tot khi benh nhan tieu hoac chch ngc dong vao
ti ong mach hang. Hai ong mach lng dng nieu ao gel lidocain nht (Hnh 25-7). Phng
vat nho hn cac ong mach hang va oi khi co the phap sau c a chuong hn v lam gian ln va co
thay c neu khao sat ngang mat lng dng vat the duy tr trong thi gian lau. Co the lam c
bang sieu am Doppler. The xop thng b ep va ieu nay khi at ong cha jelly lidocain trong vao
kho thay khi khao sat mat long cua dng vat. Tuy trong lo nieu ao va dung kep dng vat pha xa
nhien, bang lp gel va chen ep nhe bang au do, e duy tr nieu ao dng vat gian to.
co the khao sat tot the xop.
Cau truc phan am cua cac the ong nhat. Cac BAT LC
mat can bao gom tunica albuginea se thay nh
vung phan am day bao quanh ngoai bien cac cau Cho ti gan ay, ngi ta cho rang yeu to tam ly
truc the. Phai khao sat dng vat e loai tr kha hien dien trong phan ln cac nguyen nhan gay bat
nang x hoa qua mc trong cac the va/hoac trong lc. Tuy nhien cac nghien cu s dung chat lam to
dng vat vao ban em a phat hien ra phan ln
bat lc do nguyen nhan c hoc.21-25 Cac nghien
cu khac cho thay nguyen nhan mach mau la mot
trong nhng nguyen nhan thng gap cua tnh
trang that bai cng cng (Hnh 25-8).24-28 Bat lc
do nguyen nhan mach mau co the do thieu mau i
Hnh 25-5. Ky thuat sieu am dng vat. Hnh ve ky

thuat sieu am dng vat. Dng vat nam t the giai phau,
nam tren thanh bung trc. au do at tren mat long cua
dng vat. (Theo Hattery RR, King BF, Lewis RW va cong Hnh 25-6. The hang ben trai. Khao sat cat doc the hang
s. Vasculogenic impotence: duplex and color Doppler. trai (mui ten).Thanh phan am cua ong mach the hang (CA)
Radiol Clin North Am 1991; 29: 629-645. ) thay gan gia cua the hang.
sau khi tiem thuoc gian mach vao the hang, chng
to dong chay en cua ong mach va c che lam
tac tnh mach con nguyen ven. Do vay tnh trang
cng cng ay u sau tiem chat gian mach vao
the hang cho biet he thong mach mau hoan toan
bnh thng. V phng phap nay de thc hien va
co ket qua tot, no cho nhieu thuan li va c xem
la th nghiem tam soat bat lc nguon goc mach
mau. Tuy nhien, ky thuat nay khong cho phep
phan biet do bat lc nguon goc ong mach vi tnh
mach. Chan oan phan biet nay quan trong v ieu
tr bat lc nguon goc ong mach hoan toan khac
vi ieu tr bat lc nguon goc tnh mach.
Ch so dng vat-canh tay (penile-brachial
index = PBI) a tng c xem la phng phap
tam soat pho bien trong xac nh bat lc nguon goc
ong mach.27,63 Ch so nay c tnh bang cach
chia ap lc tam thu trung bnh ong mach dng
Hnh 25-7. Nieu ao bnh thng. Khao sat cat doc t
vat cho ap lc tam thu trung bnh ong mach
mat lng dng vat cho thay nieu ao bnh thng (mui ten)
canh tay. Noi chung, gia tr nho hn 0,7 gi y bat
c lam gian bang Lidocain gel. (Theo Carol B. Benson,
M.D., Boston)
lc nguon goc ong mach. Tuy nhien, cac nghien
cu cho thay viec trung lap ch so gia cac benh
nhan bnh thng va bat thng.
vao trong dng vat (bat lc nguon goc ong Khao sat Doppler duplex
mach) hoac tnh trang thoat qua mc mau tnh Viec mong muon cho mot khao sat chnh xac
mach t dng vat (bat lc nguon goc tnh mach) khong xam lan dong chay ong mach vao dng
hoac do ca hai. vat a dan ti s phat trien Doppler duplex ong
mach hang cua dng vat. Sieu am duplex chnh
Cac khao sat xam lan va khong xam lan xac hn sieu am song lien tuc v no cho phep khao
Nhieu khao sat, xam lan hoac khong xam lan, sat ong mach hang va thu c cac tn hieu
dung e anh gia lng mau ong mach vao dng Doppler xung tin cay. Dung sieu am thang xam
vat va lng mau tnh mach thoat qua mc t mo thi gian thc, Lue va cs. cho thay v tr khao sat
cng.29-73 Chup quang ong mach chau trong Doppler chnh xac va o van toc mau cua ong
chon loc c xem la tieu chuan vang trong anh mach sau cua the hang co the thc hien trc va
gia bat lc nguon goc ong sau tiem chat gian mach vao trong the hang.36 Hn
27,29,30,38,43,44,50,54,63,66
mach. Tuy nhien, ay la ky na, cac thay oi khau knh cac ong mach cung
thuat xam lan, do vay khong the la khao sat tam c anh gia trc va sau tiem gian mach. Khi
soat. Nhieu benh nhan hien tai c tam soat bat nam ro van toc dong mau va thay oi khau knh
lc do mach mau bang cach o ap ng lam sang cua ong mach hang sau tiem chat gian mach,
vi dc chat gay gian mach tiem vao trong the ngi ta co the c oan lu lng mau ong mach
hang.5,22,33,34,57,58,74 Nhieu thuoc gay gian mach san co cho dng vat cng trong qua trnh kch
ang c s dung bao gom papaverine, thch cng nhan tao.
phentolamine va prostaglandin E-1. Bang viec Ky thuat sieu am duplex cua dng vat trong
tiem thuoc gian mach vao the hang, ngi ta co the viec anh gia bat lc do mach mau tiep tuc phat
bo qua yeu to tam ly va than kinh e khi phat trien. Ky thuat nay c thc hien trong phong
bnh thng tnh trang cng. Hau het cac nha yen tnh vi s giam thieu toi a cac tac ong
nghien cu tin rang neu benh nhan at c cng khong can thiet t ben ngoai. Qua nhieu yeu to
Dng vat 829
Hnh 25-8. Cac nguyen nhan bat lc. Bieu o dang banh cat cho thay tan suat tng oi
cua cac nguon goc khac nhau cua bat lc. (Theo Quam JP, King BF, James EM va cong s.
Vasculogenic impotence: duplex and color Doppler., Radiol Soc North Am. Chicago, 1989.)
Hnh 25-9. V tr au do cho khao sat Doppler ong mach the hang. V tr tren mat lng cua dng
vat. Hnh ve cho thay au do hng vao trong, (Theo King BF Jr, Hattery RR, James EM, Lewis RW. Duplex
sonography in the evaluation of impotence: current techniques. Semin Intervent Radiol 1990; 7: 215-221.)
nhieu ben ngoai co the anh hng ti ap ng mat cat doc. trang thai cng, ong mach nay
benh nhan vi chat gian mach va anh hng ket thang hn. Gan goc dng vat, kho anh gia ong
qua o van toc. Khao sat cat doc the hang tot nhat mach hang tren sieu am thang xam. Dung Doppler
theo mat doc ben t mat long cua dng vat (Hnh mau co the giup xac nh ong mach hang tai vung
25-9). trang thai dng vat mem, ong mach nay (Hnh 25-10).
hang co the uon khuc va thay dang t oan tren
ng knh cua ong mach hang thu c la tr ngi cho rang s dung chung lng nho cua cac
so khau knh trong long mach (Hnh 25-6). Trong chat gian mach cho phep giam lng chat gian
mot so trng hp, cac ong mach hang qua nho mach, tang ap ng va giam kho chu cho benh
khong the o chnh xac trc khi tiem chat gian nhan.
mach. V s thay oi ln, nen o nhieu lan moi ieu quan trong la tiem chat gian mach chnh
ben va lay trung bnh. xac vao hai phan ba pha lng than dng vat e
Sau khi o ng knh cac ong mach hang, chat gian mach khong vao trong the xop hoac nieu
tiem chat gian mach. Cac loai va lieu lng cua ao (Hnh 25-11). Can than tranh tiem chat gian
cac chat gian mach thng dung rat thay oi. Luc mach vao trong mo di da, co the tao phu ne d
au, nhieu nha khao sat dung 60 mg papaverine doi va nguy c hoai t. Phai thong bao cho tat ca
trong 2 ml dung dch tiem vao the hang ben phai benh nhan biet neu cng cng gay au hoac neu
hoac ben trai.36 Chat gian mach de dang phan tan cng khong giam sau mot gi, benh nhan can lien
gia cac the hang v cac ca so thong noi tai vach he vi bac s ieu tr hoac vao cap cu ngay e
gia hai the hang. Cac nha khao sat khac dung anh gia va ieu tr chng cng au dng vat.
lieu thap hn (40 mg) kem theo chat gian mach th Chng cng au dng vat do thuoc la tnh trang
hai nh phentolamine (2,5 mg). Phentolamine la cng cng au lien tuc cua dng vat ton tai 1
chat c che giao cam alpha co tac dung thuc ay en 3 gi sau tiem chat gian mach vao trong the
gian c trn cua papaverine. Prostaglandin E-1 hang. Neu tnh trang nay lau hn 1 en 3 gi co
dung n oc nh chat gian c trn. Mot so khac the gay hoai t thieu mau cua mo the hang va gay
dung ca ba chat bao gom 4,4 mg papaverine, 0,15 x hoa mo cng nay. Cac benh nhan co nguy c
mg phentolamine va 1,5 microgam Prostaglandin chng cng au dng vat gom benh nhan co
E-1 trong 0,25 ml e giam toi thieu kha nang xay benh s bat lc nguon goc than kinh, benh hong
ra chng cng au dng vat (priapism), co the cau liem va benh nhan ang ieu tr heparin.
xay ra trong 2% en 8% so benh nhan.72,75 Co c phep dung cac lieu nho hoac khong dung
chat gian mach nhng benh nhan nay.74-81
ieu tr chng cng au dng vat dng vat
CAC ONG MACH THE HANG thng bao gom tiem hut ra khoang 20ml mau t
the hang. Neu chng nay khong giam, pha 20
So o Doppler bnh thng microgam phenylephrine HCL (Neosynephrine)
Van toc nh tam thu > 30 cm/giay hoa trong 1ml nc muoi sinh ly tiem vao the hang
Van toc cuoi tam trng < 3 cm/giay giup co mach nhe va ngng tnh trang cng cng.
ng knh ong mach tang 70% ieu tr chng chng cng au dng vat nen
c thc hien bi cac bac s c huan luyen tot
va co kinh nghiem.72
Hnh 25-10. ong mach the hang. A, Sieu am thang xam cat doc the hang (gii han la cac mui ten).
Khong nhan ra ong mach the hang. B, Vi Doppler mau, ong mach the hang (o) de dang xac nh.
Dng vat 831
Sau khi tiem gian mach vao trong the hang, o dong chay ong mach hoac that bai trong c che
lai ng knh va van toc dong chay ong mach ong tnh mach.
dng vat sau. Sieu am Doppler ong mach nay Bat lc nguon goc ong mach. Van toc nh
tot nhat gan goc dng vat v goc Doppler nho tam thu PSV (peak systolic velocity) sau tiem gian
nhat. Goc nay cang nho, o chnh xac cua van toc mach the hang la gia tr nhat khi anh gia benh
cang cao. Phan tch sieu am pho e o van toc nhan bat lc nguon goc ong mach. Trong nghien
nh tam thu va cuoi tam trng. cu cac ngi tnh nguyen bnh thng, PSV trung
Tac dung toi a cua chat gian mach at bnh bnh thng sau tiem gian mach khoang 30
khoang 5 en 20 phut sau chch trong hau het benh en 40 cm/giay.42 Lue va cs. thay phan ln benh
nhan nhng thi gian nay thay oi nhieu. Do vay nhan co phan ng trung bnh-kha vi papaverine
hau het cac nha khao sat khuyen nen bat au o tren lam sang co PSV ln hn hoac bang 25
van toc khoang 5 phut sau khi chch. o van toc cm/giay. Hn na, khong co benh nhan nao trong
lien tuc hoac cach khoang 5 phut trong vong t nhat nghien cu co phan ng kem sau tiem papaverine
20 en 30 phut sau chch (Hnh 25-12).2,21,22 Van ma co PSV ln hn hoac bang 25 cm/giay. Collins
toc nh tam thu va cuoi tam trng nen o tai ca va cs. cung nhan thay rang benh nhan co ap ng
hai ong mach hang cach moi 5 phut. o ng vi papaverine tren sieu am co PSV trung bnh
knh ong mach hang sau tiem 5 phut. Tac dung 26.8 cm/giay. Chung toi a bao cao loat 12 benh
chat gian mach bat au giam 20 en 30 phut sau nhan nghi ng co bat lc nguon goc ong mach co
chch. Mot so benh nhan can tiem lan hai hoac ba chup ong mach. Tat ca 5 benh nhan co dau hieu
mi at c van toc bnh thng. bat thng tren quang ong mach cung co PSV nho
Co cac dang song pho trong 5 th cua ong hn 25 cm/giay. Sau trong bay benh nhan chup
mach hang sau tiem chat gian mach vao the hang ong mach bnh thng co PSV ln hn hoac bang
benh nhan bnh thng (Hnh 25-13).42 Nam th 25 cm/giay. Cac nghien cu nay cho thay khi so
nay ngi bnh thng xay ra trong khoang 5 en sanh ap ng vi chat gian mach tren sieu am va
20 phut sau tiem gian mach. Tuy nhien benh chup ong mach, PSV nho hn 25 cm/giay cho
nhan bat thng vi nguon goc mach mau co the phep ngh ti lu lng mau ong mach khong u
khong co u cac th bnh thng v bat thng e at cng dng vat trung bnh hoac tot.
Hnh 25-11. Cac chat gian mach. Hnh ve dng vat cho thay tiem chat gian mach. Can
phai tiem vao hai phan ba than dng vat pha lng. D, mat lng; V, mat long
Hnh 25-12. Sieu am Doppler dng vat bnh thng. A va B, Doppler bnh thng
cua ong mach the hang hai ben tai phut 5, 10, 15 va 20 sau tiem chat gian mach. ng knh
ong mach nay c o trc va sau tiem.
Con tiep
Dng vat 833
Hnh 25-12. tiep theo. Xem chu thch trang oi dien.

Hnh 25-13. Cac song pho bnh thng. Song pho

trong ong mach hang trai qua 5 th sau khi tiem chat gian
mach. Th 1 xay ra trong khi xoang the hang gian, tao dang
song khang lc thap. Van toc tam trng hng ti cao nhat
trong th nay. Th 2 xay ra khi cac xoang bat au cha ay mau
va ap lc trong dng vat tang. Van toc tam thu van cao nhng
van toc tam trng bat au gan bang 0. Trong th 3, dng vat
cng to va ap lc trong dng vat bang vi huyet ap tam
trng, va dong chay tam trng chay ngc. Trong th 4 cng
cng; van toc tam thu van cao, ap lc trong dng vat vt qua
huyet ap tam trng va dong chay ngc trong tam trng xay
ra. Trong th 5, cng hoan toan va van toc tam thu bat au
giam. (Theo Schwartz AN, Wang KY, Mark LA, va cs.
Evaluation of normal erection function with color flow Doppler
sonography. AJR 1989; 153: 1155-1160.)
Benson va cs. chia nhom benh nhan bat lc Lu lng ong mach khong ch la gop phan
lam ba nhom nho da vao so lieu cua sieu cua van toc trong mach mau con la gop phan trong
am Doppler. Nhom au tien c xem bnh dien tch cat ngang cua long mach mau. V ly do
thng va co PSV trung bnh la 47 cm/giay. Nhom nay, cac nha khao sat phat trien cach o ac thay
th hai thieu mau nhe ti trung bnh co PSV 35 oi cua ng knh ong mach hang sau tiem chat
cm/giay; nhom th ba thieu mau tram trong co gian mach. Cac nha khao sat nay ngh rang kch
PSV trung bnh 7 cm/giay. Cac nha khao sat ket thc ban au cua ong mach co le khong la dau
luan gia tr ket luan c dung cho ngi bnh hieu tot cua benh ly ong mach va rang o an hoi
thng la 40 cm/giay. Cac nghien cu khac tren ong mach va kha nang gian quan trong hn.36 Ho
ngi bnh thng cho thay PSV trung bnh la 37 ngh rang tang 75% ng knh la dau hieu tot cua
cm/giay.79 Cac nha khao sat nay cho rang PSV 30 lu lng ong mach hang bnh thng. Tuy
cm/giay co the phan biet chnh xac tat ca ngi co nhien, v ong mach hang co kch thc nho va
ong mach hang bnh thng vi benh nhan co nguy c sai so trong o ng knh, khong ai da
benh ong mach tram trong. hoan toan tren s thay oi ng knh.
Dng vat 835
Hnh 25-14. Bat lc nguon goc

ong mach. A, Sieu am pho cua ong
mach hang ben phai sau tiem chat gian
mach 60mg papaverine cho thay van toc
tam thu giam khoang 15 cm/giay. B,
quang ong mach chau cho thay not can
quang ong mach hang (mui ten m).
Nhan ra ong mach lng dng vat bnh
thng (mui ten en).
T cac so lieu nay, khi PSV trong ong mach That mach mau lan toa va/hoac benh ly mach
hang nho hn 25 cm/giay sau tiem chat gian mau nho. Cac benh nhan nay cho thay khong co
mach co the ngh ti benh ly ong mach va can hoac co s thay oi nho khi o ng knh ong
co anh gia xac nh hn vi chup ong mach then mach trc va sau tiem chat gian mach. Do vay,
trong chon loc neu lam sang cho phep (Hnh 25- neu van toc qua cao ( tren 100 cm/giay), nen anh
14). Gia tr PSV gia 25 va 30 cm/giay c xem gia ky ng knh ong mach. Neu ng knh
la gii han. Van toc nh tam thu tren 35 khong thay oi ro sau tiem chat gian mach, benh
cm/giay c coi la bnh thng. Tuy nhien, co nhan co the co benh ly mach mau nho lan toa (nh
nhieu trng hp ngoai le. Neu co s khac nhau tieu ng) hoac co that mach mau lan toa
ro PSV gia hai ong mach the hang (chenh lech (nghien nicotine, cac loai thuoc).
tren 10 cm/giay), benh ly ong mach dng vat Chieu dong chay trong ong mach hang co the
mot ben co the co. u lu lng mau vao mot ao ngc. Phan chay ngc tam trng la hien
ong mach hang co the at ti s cng; tuy nhien tng bnh thng trong giai oan tre cua cng
benh ly ong mach mot ben co the ro trong mot so cng. Tuy nhien, khong bao gi thay dong chay
ca nhan va chup ong mach can c thc hien. ngc trong th tam thu. Dong chay ngc tam thu
Mot ngoai le khac xay ra khi PSV cao hn 100 thng do tac ong mach dng vat oan gan
cm/giay. Van toc cao nay thay benh nhan co co vi tuan hoan bang he chay ngc vao trong ong
836
mach hang b ton thng. Tac ong mach dng nhan lien tuc co van toc cuoi tam trng cao (tren
vat oan gan co the do chan thng, x hoa the 3 cm/giay) tre trong khao sat ( 15 en 20 phut sau
hang hoac benh ly x va mach mau. tiem), du co dong chay ong mach bnh thng (
Tuan hoan bang he vao ong mach hang co PSV 30 cm/giay) co the co bat lc do nguyen nhan
the la bien oi bnh thng. Tuy nhien, tuan hoan tnh mach40 (Hnh 25-15). Nen thc hien o the
bang he t ong mach hang oi ben hoac ong hang va chup the hang cac benh nhan nay. Benh
mach lng dng vat co the cho thay ton thng nhan co ao ngc dong chay tam trng trong ca
ong mach oan gan. Cac tuan hoan bang he nay hai ong mach hang th co c che ong tnh mach
co the thay bang sieu am Doppler. bnh thng.
Can ac biet chu y neu co ro xoang ong mach Tnh mach lng sau dng vat dan lu phan ln
hoac ro ong-tnh mach trong mo the hang benh mau tnh mach t the hang. Mot so nha khao sat
nhan co roi loan cng cng sau chan thng. e ngh o van toc tnh mach lng sau e anh
anh gia bang Doppler co the xac nh ro. Chng gia ro mau tnh mach. Tuy nhien, cac ket qua
cng au dng vat mot phan thng kem theo trc ay cho thay ca ngi bnh thng va benh
dau hieu ro xoang ong mach. nhan co ro tnh mach co the co van toc tnh mach
Bat lc nguon goc tnh mach. Co the do ro lng sau cao.71 Hn na, cung phat hien mot so
r mau tnh mach qua mc t cac the cua dng benh nhan co ro tnh mach tren o va chup the
vat. Du khong ro nguyen nhan chnh xac cua ro, hang co the ro nguyen phat tai tnh mach goc gan
nhieu nha khao sat cho rang do th phat cua cang goc dng vat va khong ro tai tnh mach lng sau
gian lp trang (tunica albuginea). Viec cang gian dng vat. Do vay, co le o van toc tnh mach
nay ngan can s chen ep cua cac tnh mach lien lng sau dng vat khong hu ch trong tam soat
lac, lng mau tnh mach thoat ra ngoai tiep tuc bat lc nguon goc tnh mach.
tang t mo cng va s cng khong bao gi xay Cac bay trong sieu am Doppler duplex
ra tron ven. trong benh bat lc.
Trc ay, bat lc nguon goc tnh mach c Thi gian e o van toc. Cac nha khao sat
anh gia bang o the hang va chup hnh the trc ay e ngh o van toc sau khi tiem 5 en 10
hang.47-51,55,60 Tuy nhien, cac khao sat nay xam lan phut. Tuy nhien, cac nghien cu gan ay cho thay
va khong thch hp cho muc ch tam soat. Do ap ng vi thuoc gian mach trong the hang thay
vay, sieu am duplex c dung gan ay nh la oi cac ca nhan.72,82-84 PSV nam gii bnh
phng phap tam soat bat lc nguon goc tnh thng co the xay ra bat c luc nao t 5 en 30
mach. phut sau tiem. Do o, e o c van toc toi a
Khao sat Doppler duplex cua ong mach nen o tai phut th 5, 10, 15, va 20 sau chch.
the hang ngi bnh thng. Trong khi khao V ngi bnh thng co van toc cuoi tam
sat, co s gia tang van toc tam trng va tam thu trng sm khi khao sat ( 5 en 10 phut sau tiem),
ngay sau tiem chat gian mach vao the hang. ieu nhieu nha khao sat thay nen o van toc cuoi tam
nay do phan ng vi gian sinh ly cua ong mach trng tai phut 15, 20 va 30 khi tam soat bat lc
hang, ong mach xoan va cac xoang. Khi cac nguon goc tnh mach. Dang song pho khang lc
xoang gian va o ay mau, khang lc ong mach thap lien tuc tai thi iem tre nay (van toc cuoi
hang giam va dong chay ti tam trng gia tang. trng cao hn 5 cm/giay) cho phep ngh ti ro
Tuy nhien, khi c che ong tnh mach bat au, cac mau tnh mach qua mc gay bat lc.
xoang tr nen gian toi a va ap lc trong the hang Du ngi ta cho rang tiem chat gian mach vao
gia tang. Tai thi iem nay, khang lc mach mau the hang se giup bo qua kch thch tam ly gay
tang va dong chay tam trng ngng lai hoac ao cng, anh hng tam ly qua mc co the lam giam
ngc. Neu benh nhan co c che ong tnh mach ap ng vi chat gian mach. PSV di nh (< 25
khong hoan toan, ro mau tnh mach xay ra va ap cm/giay) co the xay ra trong ngng bnh thng
lc trong the hang thap. Dang song se tiep tuc co ma co lo lang qua mc va trng lc giao cam
dang dong chay tam trng hng ti vi khang alpha-adrenergic.85,86 oi khi, nhieu benh nhan tr
lc thap suot qua trnh khao sat. Do vay, benh nen qua lo lang ve tiem chat gian mach va/hoac
Dng vat 837
Hnh 25-15. Bat lc nguon goc tnh mach.

A, Sieu am pho ong mach hang ben trai 15 phut
sau tiem cho thay van toc nh tam thu bnh thng
44 cm/giay. Tuy nhien, van toc cuoi tam trng
cao lien tuc 14 cm/giay ngh ti ro mau tnh mach
qua mc. B, Chup the hang cho thay ro tnh mach
ln vao am roi sau xng mu (mui ten ).
ve sieu am dng vat. V s lo lang nay, ap ng lng mau ong mach kem. Moi benh nhan nen
vi chat gian mach b c che. Chung toi thay 26% c t van ve tnh an toan cua ky thuat va tieu
khong ap ng (< 30 cm/giay) vi lan tiem au se chuan nghiem can duy tr trong khi khao sat.
ap ng vi lan tiem th hai va ba. V vay, chung Phong toi yen lang co the giup benh nhan bt s
toi thng qui tiem lai sau 20 phut neu benh nhan set.
khong ap ng vi lan tiem au. Neu sau 10 phut, Tiem chat gian mach khong ung cach. Neu
benh nhan khong ap ng vi lan chch th hai, chch vao the xop, mo xoang khong co chat gian
chung toi chch lan ba. Neu lan ba khong ap ng, mach va khong at viec cng. Hn na chat gian
chung toi dng lai va ket luan benh nhan co lu mach co the vao nieu ao va chay ra lo ai.
BENH PEYRONIE
Benh Peyronie la qua trnh x hoa cua cac bao si

bao phu the hang. Tnh trang nay xay ra khong ro
nguyen nhan, thng tren 40 tuoi. Vung x hoa
nay oi khi khong cho phep dng vat dai ra khi
cng cng, do vay dng vat b be cong. Vung x
hoa thng lien quan vung lng dng vat nhng
co the lien quan vach dng vat va/hoac vung ben Hnh 25-16. Mang x dng vat. Sieu am doc mat trong
dng vat. Be cong dng vat hng ti vung co cua the hang phai cho thay mang x phan am (mui ten ) kem
mang x gay ra bien dang goi la chordee (chng bong lng.
cong dng vat). Neu au kem theo trong giai
oan sm cua cng va cuoi cung mc o cong co
the khong cho phep giao hp c. Ngi ta tin
rang qua trnh nay bat au nh mot viem mach
mau cua bao mo lien ket di lp trang va sau o qua nga hau mon. Co the khao sat nieu ao trc
lan ti cau truc lan can. No dan ti x hoa va sau bang cach at au do tren be mat dng vat va
o voi hoa hoac cot hoa. lam gian nieu ao bang dch hoac gel.
S nan than dng vat co the thay mang x Ch nh sieu am nieu ao dng vat bao gom
gii han ro thng ng gia lng gan goc anh gia hep nieu ao va tam soat d vat hoac soi.
dng vat du co the nam ben hoac pha xa dng Sieu am cung dung trong chan thng nieu ao
vat. Chup X quang dng vat thay vung voi hoa hoac tui tha nieu ao.96-100
ben trong vung b cng. Hep nieu ao thng xay ra th phat sau viem
Tren sieu am, cac mang x cua benh Peyronie nieu ao do lau cau hoac chan thng. anh gia
hien len di dang nhng vung phan am day tang sieu am cua hep nieu ao co nhieu thuan li hn X
am gan b ngoai cua the hang, thng doc theo quang. Sieu am khong gay nhiem xa, rat quan
lng dng vat.1,3,53,87-95 Trong mot nghien cu, trong oi benh nhan tre co hep ma co the can khao
22% mang x xac nh tren sieu am ma lam sang sat nhieu lan. Trong khi sieu am thi gian thc
khong s thay. Khoang 33% benh nhan cac mang tren mat ngang hoac doc, sieu am ba chieu cua
x co bong lng do voi hoa (Hnh 25-16). Trong nieu ao co thuan li. Co the khao sat seo hoac
mot so trng hp hiem, benh Peyronie co ton cac ton thng khac tai cac mo mem quanh nieu
thng phan am kem tao hnh anh mo quanh hang ao. Bat li cua sieu am nieu ao dng vat la
to. Hnh anh nay thng giai oan sm nhat cua khong the thay nieu ao sau neu khong khao sat
benh, khi co qua trnh x hoa rai rac va phu mo ke. qua nga hau mon. Tuy nhien, a so hep nieu
Qua trnh x hoa va mang x co the lan rong vao ao trc.
the hang va lam tac ong mach hang. Viec tac nay Long nieu ao bnh thng o < 4 mm khau
co the gay bat lc. knh va thanh mong. Hep nieu ao trc xay ra
Sieu am co the anh gia kch thc va v tr khi long hep co thanh day bat thng khong eu
cua mang x trc phau thuat. Sieu am co the do x hoa va hoa seo (Hnh 25-17). Co the o
theo doi sau khi ieu tr e anh gia thoai trien cua chnh xac chieu dai hep va co the thay gian nieu
mang x. ao gan hep. Co the thc hien nong nieu ao di
sieu am hng dan khi co ch nh.
NIEU AO DNG VAT Cac d vat khong can quang hoac soi can
quang nieu ao co the thay di sieu am. Khi
Nieu ao nam bao gom nieu ao sau (gom nieu tam soat vat la trong nieu ao, phai quet nieu ao
ao tuyen tien liet va nieu ao mang) va nieu ao dng vat va nieu ao hanh trc khi lam gian
trc (nieu ao hanh va nieu ao dng vat). nieu ao e nh v vat la v no co the bat ra khi i
anh gia sieu am nieu ao sau co the thc hien ngc dong.
Dng vat 839
Hnh 25-18. Ro xoang-ong mach. Doppler mau cat

ngang cho thay vung co dong chay mau tang lien quan ti phan
Hnh 25-17. Hep nieu ao. Hnh sieu am cat doc cho thay ln mo the hang ben phai, ngh ti ro xoang-ong mach. (Theo
hep nieu ao khu tru (dau thap). U, nieu ao. (c phep cua Hattery RR, King BF, va cs.. Vasculogenic impotence: duplex
Carol B. Benson, M.D., Boston) and color Doppler. Radiol Clin North Am 199; 29: 629-645.)
Tui tha nieu ao nieu ao dng vat hiem toa cua u nguyen phat va no lien quan ti cac mo
nhng co the xay ra do viem nieu ao trc ay. cac the. Ung th dng vat co the co phan am
Tui tha nay co hnh tui ay dch nam sat nieu kem hoac day. B u thng thay ro va co the thay
ao. Cac tui tha nay co the thay di sieu am ma ro lan toa vao mo cac the.85 Trong ung th dng
khong lap ay khi chup nieu ao ngc dong. vat, phau thuat u can phai cach b u 2 cm.
CARCINOMA DNG VAT CHAN THNG DNG VAT
Hau het carcinoma dng vat co nguon goc t bieu Chan thng gom loai xuyen thau ( v du dao hoac
mo va lien quan ti phan xa dng vat.93,101,102 Tan an) hoac kn.103 Ton thng dng vat sau chan
suat cua carcinoma dng vat thap hn dan so co thng kn thng xay ra khi dng vat cng
cat bao qui au. Carcinoma giai oan I lien quan cng. Gay dng vat xay ra khi co rach lp trang
ton thng gii han vung qui au hoac da qui au. va the hang.104,105 Gay thng lien quan vi rach
Giai oan II u xam lan than dng vat hoac the nieu ao. Du cac dau hieu lam sang ro, sieu am
hang. Giai oan III u xam lan than va co hach van hu ch trong viec anh gia mach mau.106
vung. Giai oan IV u co di can xa. mot so ca nhan, ro xoang ong mach xay ra sau
Khoang 50% benh nhan co di can tai hach ton thng vi hai chan dang ra. Ro xoang ong
vung ben tai thi iem chan oan v benh khong mach hiem hoi nay gay sng phu mot phan dng
gay au va thng nam kn trong phan da qui au. vat.65,106 Sieu am thang xam cua vung nay co the
Chan oan sm di can hach la cach tot nhat trong cho thay vung giam phan am do khoi mau tu trong
quan ly va tien lng. Sinh thiet bang choc hut the hang. Doppler mau se thng cho thay ro hn
kim nho di sieu am cac hach ph ai co the giup hnh anh ro ong-tnh mach cua mo the hang (Hnh
anh gia trc mo cac benh nhan nay.102 25-18).
Sieu am vi o phan giai cao cho thay s lan
THAM KHAO AH, ed. Management of Male Impotence. Baltimore: Williams

& Wilkins: 1982.
Giai phau hoc 24. Krane RJ, Goldstein I, Saenz de Tejada I. Medical progress:
1. Rollandi GA, Tentarelli T, Vespier M. Computed tomo - impotence. N Engl J Med 1989: 321: 1648 - 1659.
graphic findings in Peyronie's disease. Urol Radiol 1985; 153 - 25. Shabsigh R, Fishman IJ, Scott FB. Evaluation of erectile
156. impotence. Urology 1988: 32: 83 - 90.
2. Fisher M, Kricum M. Imaging of the Pelvis. Rockville, Md: 26. Mueller SC, Lue TF. Evaluation of vasculogenic impotence.
Aspen Publishers, Inc. ; 1989. Urol Clin North Am 1988: 15: 65 - 76.
3. Hricak H, Marotti M, Gilbert TJ et al. Normal penile anatomy 27. Chiu RC, Lidstone D, Blundell PE. Predictive power of penile
and abnormal penile conditions: evaluation with MR imaging. brachial index in diagnosing male sexual impotence. Vasc
Radiology 1988; 169: 683 - 690. Surg 1986: 4: 251 - 256.
Sinh ly hoc 28. Wagner G, Uhrenholdt A. Blood flow by clearance in the
4. Aboseif SR, Lue TF. Hemodynamics of penile erection. Urol human corpus cavernosum in the flaccid and erect states. In:
Clin North Am 1988; 15: 1 - 7. Zorgniotti AW, Rossi C, eds. Vasculogenic Impotence:
5. Stackl W, Hasun R, Marberger M. Intracavernous injection of Proceedings of the First International Conference on Corpus
prostaglandin El in impotent men. J Urol 1988; 140: 66. Cavernosum Revascularization. Springfield, III: Charles C.
6. Fujita T, Shirai M. Mechanism of erection. Clin Exp Med Thomas, Publisher; 1980.
1989; 148: 249. 29. Forsberg L, Olsson AM, Neglen P. Erectile function before
7. Sliirai M, Ishii N. Hemodynamics of erection in man. Arch and after aorto - iliac reconstruction: a comparison between
Androl 1981: 6: 27. measurements of Doppler acceleration ratio, blood pressure
8. Tudoriu T, Bourmer H. The hemodynamics of erection at the and angiography. J Urol 1982: 127: 379 - 382.
level of the penis and its local deterioration. J Urol 1983: 129: 30. Velcek D, Sniderman KW. Vaughan ED et al. Penile flow
741 - 745. index utilizing a Doppler pulse wave analysis to identify
9. Saenz de Tejada IS, Goldstein I, Krane RJ. Local control of penile vascular insufficiency. J Urol 1980: 123: 669 - 672.
penile erection: nerves, smooth muscle and endothelium. Urol 31. Bookstein . IJ. Penile vascular calheterization in the diagnosis
Clin North Am 1988: 15: 9 - 15. and treatment of impotence. Cardiovasc Intervent Radiol 1988,
10. Newman HF, Northup JD, Delvin J. Mechanism of human 11 (special issue): 183 - 261.
penile erection. Invest Urol 1963: 1: 350 - 353. 32. Bookstein JJ, Vaiji K, Parsons L, Kessler W.
11. Lue T. Tanagho E. Physiology of erection and pharmacologic Pharmacoarteriography in the evaluation of impotence. J Urol
management of impotence. J Urol 1987: 137: 829. 1987: 137: 333 - 337.
12. Saenz de Tejada IS, Goldstein I, Kranc RJ. Local control of 33. Virag R, Frydman D, Legman M et al. Intracavernous
penile erection: nerve, smooth muscle and cndothelium. Urol injection of papaverine as a diagnostic and therapeutic method
Clin North Am 1988: 15: 9 - 15. in erectile failure angiology. Vasc Dis 1984: 35: 79 - 87.
13. Shirai M, Ishii N, Mitsukawa S et al. Hemodynamic 34. Buvat J, Bervat - Hertaut M, Dehaene JL et al. Is intravenous
mechanism of erection in the human penis. Arch Androl 1978: injection of papaverine a reliable screening test for
1: 345 - 349. vasculogenic impotence. J Urol 1986: 135: 476 - 478.
14. Beutler LE, Gleason DM. Integrating the advances in the 35. Robinson LQ, Woodcock JP, Stephenson TP. Duplex scanning
diagnosis and treatment of male potency disturbance. J Urol in suspected vasculogenic impotence: a worthwhile exerise. Br
1981; 126: 338 - 342. J Urol 1989: 63: 432 - 436.
15. Gollins WE, McKendry JBR, Silverman M et al. Multi - 36. Lue TF, Hricak H, Marich KW et al. Vasculogenic impotence
disciplinary survey of erectile dysfunction. Can Med Assoc J evaluated by high - resolution ultrasonography and pulsed
1982: 128: 1393 - 1399. Doppler spectrum analysis. Radiology 1985: 155: 777 - 781.
16. Hirsch IH, Smith RL, Chancellor MB et al. L'se of 37. Desai KM, Gingell JC, Skidmore R et al. Application of
intracavernous injection of prostaglandin El for neuropathic computerized penile arterial waveform analysis in the
erectile dysfunction. Paraplegia 1994: 32: 661 - 664. diagnosis of arteriogenic impotence: an initial study in potent
and impotent men. Br J Urol 1987; 60: 450 - 456.
17. Pickard RS, King P, Zar MA et al. Corpus cavernosal
relaxation in impotent men. Br J Urol 1994: 74: 485 - 491. 38. Collins JP, Lewandowski BJ. Experience with intracorporeal
injection of papaverine and duplex ultrasound scanning for
18. Lug TF, Tanagho EA. Physiology of erection and
assessment of arteriogenic impotence. Br J Urol 1987: 59: 84 -
pharmacological management of impotence. J Urol 1987; 137:
88.
829 - 836.
39. Krysiewicz S, Mellinger BC. The role of imaging in the
19. Lue TF, Zeineh RA, Schmidt RA et al. Physiology of erection.
diagnostic evaluation of impotence. AJR 1989; 153: 1133 -
World J Urol 1983; 1: 194 - 196.
1139.
Bat lc 40. Quam JP, King BF, James EM et al. Duplex and color Doppler
20. Masters WH, Johnson VE. Human Sexual Inadequacy. New sonographic evaluation of vasculogenic impotence. AJR 1989:
York: Little, Brown, & Co Inc; 1970. 153: 1141 - 1147.
21. Karacan I, Salis PJ, Williams RL. The role of the sleep 41. Benson CB, Vickers MA. Sexual impotence caused by
laboratory in the diagnosis and treatment of impotence. In: vascular disease: diagnosis with duplex sonography. AJR 1989:
William RL, Karacan I, Frazier SH, eds. Sleep Disorders: 153: 1149 - 1153.
Diagnosis and Treatment. New York: John Wiley & Sons Inc; 42. Schwartz AN, Wang KY, Mack LA et al. Evaluation of normal
1978. erectile function with color flow Doppler sonography. AJR
22. Abber 1C, Lue TF, Orvis BR et al. Diagnostic tests for 989; 153: 1155 - 1160.
impotence: a comparison of papaverine injection with the 43. Paushter DM. Role of duplex sonography in the evaluation of
penile - brachial index and nocturnal penile tumescence sexual impotence. AJR 1989; 153: 1161 - 1163.
monitoring. J Urol 1986: 3 - 28. 44. Lue TF, Hricak H, Marich KW et al. Evaluation of
23. Karacan I, Moore CA. Nocturnal penile tumescence: an arteriogenic impotence with intracorporeal injection of
objective diagnostic aid for erectile dysfunction. In: Bennett
Dng vat 841
papaverine and the duplex ultrasound scanner. Semin Urol 69. Hattery RR - King BF, Lewis RW et al. Vasculogenic
1985; 3: 43 - 48. impotence: duplex and color Doppler. Radiol Clin North Am
45. Gall H, Barhren W, Scherb W et al. Diagnostic accuracy of 1991; 29: 629 - 645.
Doppler ultrasound technique of the penile arteries in 70. Hattery RR, King BF Jr. James EM et al. Vasculogenic
correlation to selective arteriography. Cardiovasc Intervent impotence: duplex and color Doppler imaging. AJR 1991: 156:
Radiol 1988; 11: 225 - 231. 189 - 195.
46. Bookstein JJ. Penile angiography: the last angiographic 71. Quam JP, King BF, James EM et al. Duplex and color Doppler
frontier. AJR 1988; 150: 47 - 54. ultrasound evaluation of vasculogenic impotence (scientific
47. Lue TF, Hricak H, Schmidt RA et al. Functional evaluation of exhibit). Radiol Soc North Am, 1989.
penile veins by cavernosography in papaverine - induced 72. King BF Jr, Hattery RR, James EM, Lewis RW. Duplex
erection. J Urol 1986: 135: 479 - 482. sonography in the evaluation of impotence: current techniques.
48. Lewis RW. This month in investigative urology: venous Semin Intervent Radiol 1990: 7: 215 - 221.
impotence. J Urol 1988: 140: 1560. 73. King BF Jr. Color Doppler flow imaging evaluation of the
49. Bookstein JJ. Cavernosal veno - occlusive insufficiency in deep dorsal penile vein in vascular impotence (abstract).
male impotence: evaluation of degree and location. Radiology Radiol Soc North Am 1989: 371.
- 1987: 164: 175 - 178. 74. Tanaka T. Papaverine hydrochloride in peripheral blood and
50. Malhotra CM, Baiko A, Winczc JP et al. Cavernosonography the degree of penile erection. J Urol 1990: 143: 1135 - 1137.
in conjunction with artificial erection for evaluation of venous 75. Broderick GA, Harkaway R. Pharmacologic erection: time -
leakage in impotent men. Radiology 1986: 161: 799 - 802. dependent changes in the corporal environment. Int J Impot
51. Lewis RW. Venous surgery for impotence. Urol Clin North Res 1994: 6: 9 - 16.
Am 1988: 15: 115 - 121. 76. Burkhaller J, Morano J. Partial priapism: the role of computed
52. Rajfer J, Canan VP, Dorey FJ et al. Correlation between tomography in its diagnosis. Radiology - 1985: 156: 1o9.
penile angiographv and duplex scanning of cavernous arteries 77. Abozeid M, Juenemarm K. Luo J et al. Chronic papaverine
in impotent men. J Urol 1990: 143: 1128 - 1130. treatment: the effect of repeated injections on the simian
53. Montague D. Noninvasive Vascular Evaluation in Disorders of erectile response and penile tissue. J Urol. 1987: 138: 1263.
Male Sexual Function. Chicago: Year Book Medical 78. Summers J. Pyogenic granuloma: an unusual complication of
Publishers Inc: 1988. papaverine injection therapy for impotence. J Urol 1990: 143:
54. Vickers M, Benson C, Richie J. High - resolution 1227 - 1228.
ultrasonographv and pulsed wave Doppler for detection of 79. Virag R. About pharmacologically induced prolonged erection
corporovenous incompetence in erectile dysfunction. J Urol (letter to the editor). Lancet 1985: 1: 519.
1990: 143: 1125 - 1127. 80. Hu K, Burks C, Christy W. Fibrosis of tlie tunica albuginea:
55. Datta NS. Corpus cavernosography in conditions other than complication of long - term intracavernous pharmacological
Peyronie - s disease. J Urol 1977: 118: 588 - 590. self - injection. J Urol 1987: 138: 404.
56. Grav R, Keresteci A, St Louis E et al. Investigation of 81. Kiely E, Williams C. Goldie 1. . Assessment of the immediate
impotence bv internal pudendal angiography; experience with and long - term effects of pharmacologically induced penile
73 cases. Radiology - 1982: 144: 773 - 780. erections in the treatment of psychogenic and organic
57. Lakin M, Montague D, Medendorp S et al. Intracavernous impotence. Br J Urol 1987: 59: 164.
injection therapy: analysis of results and complications. J Urol 82. Govier FE, Asase D, Hefty TR et al. Timing of penile color
1990: 143: 1138 - 1141. flow duplex ultrasonography using a triple drug mixture. J
58. Virag R, Frydman D, Legman M et al. Intracavernous Urol 1995: 153: 1472 - 1475.
injection of papaverine as a diagnostic and therapeutic method 83. Kirn SH, Paick JS, Lee SE et al. Doppler sonography of deep
in erectile failure. Angiology 1984: 35: 79. cavernosal artery of the penis: variation of peak systolic
59. Goldstein I, Sirokv M, Nath R et al. Vasculogenic impotence: velocity according to sampling location. J Ultrasound Med
role of the pelvic steal test. J Urol 1982: 128: 300. 1994: 13: 591 - 594.
60. Fournier G. Juenemann K, Lue T et al. Mechanisms of venous 84. Fitzgerald SW, Erickson SJ, Foley WD et al. Color Doppler
occlusion during canine penile erection: an anatomic sonography in the evaluation of erectile dysfunction: patterns
demonstration, J Urol 1987; 137: 163. of temporal response to papaverine. AJR 1991: 157: 331 - 336.
61. Mellinger BC, Vaughan ED Jr, Thompson SL et al. 85. Lee B, Sikka SC, Randrup ER et al. Standardization of penile
Correlation between intracavernous papaverine injection and blood flow parameters in normal men using intracavernous
Doppler analysis in impotent men. Urology 1987: 416 - 419. prostaglandin El and visual sexual stimulation. J Urol 1993;
62. Vira R, Bouilly P, Frydman D. Is impotence an arterial 149: 49 - 52.
disorder. A study of arterial risk factors in 440 impotent men. 86. Knispel HH, Andresen R. Color - coded duplex sonography in
Lancet 1985: 1: 181 - 184. impotence: significance of different flow parameters in
63. Abelson D. Diagnostic value of the penile pulse and blood patients and controls. Eur Urol 1992; 21: 22 - 26.
pressure: a Doppler study of impotence in diabetics. J Urol
Benh Peyronie
1975; 13: 636 - 639.
87. Balconi G, Angeli E, Nessi R et al. LJltrasonographic
64. Nessi R, de Flaviis L, Bellizoni G et al. Digital angiography of
evaluation of Peyronie's disease. Urol Radiol 1988; 10: 85 -
erectile failure. Br J Urol 1987: 59: 584 - 589.
88.
65. Ginestie JP, Romieu A. Radiologic Exploration of Impotence.
88. Metz P, Ebbehoj J, Uhrenholdt A et al. Peyronie's disease and
Boston: Nijhoff; 1978.
erectile failure. J Urol 1983; 30: 1103 - 1104.
66. Puvau FA, Lewis FW. Corpus cavernosography: pressure.
89. Altraffer LF, Jordan JH. Sonographic demonstration of
flow and radiography. Invest Radiol 1983: 18: 517 - 522.
Peyronie's plaques. Urology 1981; 17: 292 - 295.
67. Delcour C, Wespes E, Vandenbosch G et al. Impotence:
90. Fleischer AC, Rhamy RK. Sonographic evaluation of
evaluation with cavernosography. Radiology 1986: 161: 803 -
Peyronie's disease. Urology - 1981; 17: 290 - 291.
806.
91. Gelbard M, Sarti D, Kanfman J. Ultrasound imaging of
68. Maatman TJ, Montague DK, Martin LM. Cost - effective
Peyronie's plaques. J Urol 1981: 125: 44 - 45.
evaluation of impotence. Urology 1986; 27: 132 - 135.
92. Merkle W. Cause of deviation of the erectile penis after Med 1988; 7: 107 - 109.
urethral manipulations (Kelami syndrome): demonstration of 100. Merkle W, Wagner W. Sonography of the distal male urethra
ultrasound findings and case reports. Urol Int 1990; 45: 183 - a new diagnostic procedure for urethral stricture: results of a
185. retrospective study. J Urol 1988; 140: 1409 - 1411.
93. Rifkin M. Urethra and penis. In: Diagnostic Imaging of the
Carcinoma dng vat
Lower Genitourinary Tract. New York: Raven Press: 1985.
101. Sufrin G, Huben R. Benign and malignant lesions of the penis.
94. Vermooten V. Metaplasia in the penis: the presence of bone,
In: Cillenwater J. Grayhack I, Howards S et al, eds. Adult and
bone marrow and cartilage in the glans. N Engl J Med 1933:
Pediatric Urology: Chicago: Year Book Medical Publishers
209: 368 - 369.
Inc; 1987.
95. Frank R, Gerard P, Wise G. Human penile ossification: a case
102. Scappini P, Piscioli F, Pusiol T, Hofstetter A et al. Penile
report and review of the literature. Urol Radiol 1989; 11: 179 -
cancer; aspiration biopsy cytology for staging. Cancer 1986;
181.
58: 1526 - 1533.
Nieu ao dng vat
Chan thng dng vat
96. Benson CB. Sonography of the male urethra. Current status of
103. Smith D. General Urology: Injuries to the Genitourinary Tract.
prostate and lower urinary tract imaging course. AIUM Annual
Los Altos, Calif: Lange Medical Books, 1978: 233 - 252.
Meeting; March 3 - 4, 1990; New Orleans.
104. Grosman H, Gray R. St Louis L et al. The role of corpus cav -
97. McAninch JW, Laing FC, Jeffrey RB. Sonourethrography in
ernosography in acute "fracture"' of the penis. Radiology -
the evaluation of urethral strictures: a preliminary report. J
1982; 144: 787 - 788.
Urol 1988; 139: 294 - 297.
105. Aines ES, Newhouse JH, Gronan J. I. Radiology of male peri -
98. Gluck CD, Bundy AL, Fine C et al. Sonographic urethrogram:
urethral structures. AJR 1988; 151: 321 - 324.
a comparison to roentgenographic techniques in 22 patients. J
106. Dierks PR, Hawkins H. Sonography and penile trauma. J
Urol 1988; 140: 1404 - 1408.
Ultrasound Med 1983; 2: 417 - 419.
99. Kauzlaric D, Barmeir E, Peyer P et al. Sonographic
appearances of urethral diverticulum in the male. J Ultrasound
C H N G 2 6
Chop xoay

Marnix T. van Holsbeeck, M.D.
Laurence A. Mack, M.D.
Frederick A. Matsen III, M.D.
Keith Y. Wang, Ph.D., M.D.
c chop xoay. ien hnh cac si gan tren gai ton

D A N B A I thng trc. Gan c di vai va di gai, hai gan
khac cua chop xoay, se ton thng khi vet rach
NHAN XET LAM SANG rong ra. Gan c tron nho, thanh phan th t cua
NHAN XET KY THUAT
chop xoay, hiem khi b anh hng. Viem gan voi
KY THUAT
hoa, benh re tuy co, va viem khp cung on co the
CHOP XOAY BNH THNG
gay lam vi benh ly chop xoay. T lau, chup khp
Chop xoay ngi trng thanh
co chat can quang la phng tien X quang hang
Nhng bien oi lien quan en tuoi tac
BIEU HIEN TRC MO
au chan oan rach toan bo be day chop xoay. Hai
Tieu chuan rach chop xoay ky thuat hnh anh khong xam nhap canh tranh vi
Khong thay chop xoay nhau, Cong hng t (MRI) va sieu am, ang ngay
Khong thay mot phan chop xoay cang lan lt vai tro cua chup khp co chat can
Chop xoay mat lien tuc quang. Sieu am phan giai cao hien th tc th a
Phan am bat thng khu tru c chng minh la phng tien co hieu qua kinh
Cac dau hieu ket hp te trong viec khao sat chop xoay. Sieu am la
Tran dch tui hoat dch di c delta phng cach c chon dung trong benh vien cua
Tran dch trong khp chung toi. Trong 5 nam qua chung toi a thc hien
Lom ng vien m di c delta nghien cu sieu am tren 6.000 khp vai.
Be mat xng khong eu
BIEU HIEN SAU MO NHAN XET LAM SANG
Rach tai phat
CAC BAY
Ton thng cac si gan chop xoay1 la nguyen nhan
gay au khp vai va mat chc nang thng gap
nhat benh nhan tren 40 tuoi. Nghien cu dch te
Chng au khp vai co nhieu nguyen nhan. hoc cua Codman, DePalma, va cac tac gia khac a
Viem gan, cang chop qua mc va rach toan bo hay chng to rang ty le ton thng cac si gan chop
mot phan be day chop xoay se gay au va gi tay xoay tang len theo tuoi.9-11 S lao hoa gan nay
len kho khan. Cn au trong benh ly chop xoay cung c chng minh trong cac nghien cu ve
thng tang len ve em va co the gay thc giac hnh anh hoc.12-15 Nhng bien oi sm nhat thng
kha lau. Ban chat cua nhng trieu chng nay xay ra chat lieu cua gan, tao cai goi la tach lp
benh nhan tren 40 tuoi la s ton thng cac si gan (delamination) chop xoay. Thoai hoa si la qua
trnh tien trien tng bc t rach mot phan be day, hng gan(tendon anisotropy). Anh gia cuoi cung
hau nh luon luon xay ra au tien gan c tren va nen hnh thanh do cau truc d hng cua gan.
gai, en rach rong ra nhieu gan chop xoay khac. Tnh song song cua cac cau truc collagen tao nen
Rach chop xoay co the xay ra am tham va tnh chat hnh anh khac thng: o phan am cua
trong thc te, benh nhan khong phat hien ra, mot gan phu thuoc vao goc cua au do so vi gan khi
qua trnh ma mot so tac gia goi la rach gan kieu khao sat. Be mat cong cua au do sector c hoc se
ron ren(creeping). Rach gan khong trieu chng tao nen hnh anh khong ong nhat cua gan. Ngay
xay ra 30% ngi tren 60 tuoi.12 Khi mot nhom ca vi ky thuat vuong goc toi u, trung tam cua
ln cac si b ton thng cung mot luc, khp vai se anh se co phan am tang trong khi hai ben anh lai
au luc ngh va au tang len khi s dung chop co phan am kem. Ngi lam thieu kinh nghiem co
xoay. (Th du nh duoi, dang hoac xoay ngoai). the lam o phan am kem nay la benh ly.
Ngay ca khi nhieu si hn b ton thng cung luc, Vi ky thuat hien ai, hnh anh chop xoay
hien tng vai cap se bieu hien bang s khi c khao sat bang au do thang co o phan giai
phat ot ngot rat kho gap, dang va xoay ngoai vai. cao. au do co o phan giai cao 7 hoac 7,5 MHz
Cang ln tuoi, chop xoay se tr nen cang de c a dung hn loai tan so thap hn. nhng
rach du vi lc tac ong khong qua manh. Do o, benh nhan co lp di da mong, hien chung toi
mac du ngi 40 tuoi lc tac ong phai u manh dung au do thang 10 MHz mot cach thng qui.
mi lam rach c chop xoay bnh thng, con Nhng au do nay cho thay s cai thien ro net o
nhng ngi tren di 60 tuoi ch can mot lc phan giai gan so vi nhng au do khac. Ngoai ra
tng oi khong ang ke a co the lam rach chop trng quan sat nong rong cung giup cai thien hnh
xoay cua ho. ieu nay tng t nh nguy c cao anh vung gan.
gay co xng ui phu n co tuoi. Mac du s khac
biet ve hnh dang mom cung, bat thng khp cung KY THUAT
on, va nhng yeu to khac co the lam chop xoay
co nguy c de b ton thng, s thoai hoa theo tuoi Nam vng giai phau hoc ba chieu phc tap cua
va sc tai tren chop xoay dng nh la nhng chop xoay trong luc sieu am la rat quan trong e
nguyen nhan noi bat quyet nh dang ton thng at c thanh cong trong sieu am chop xoay.
cua cac gan chop xoay. Xng co the lam gii han kha nang khao sat cua
Trieu chng ton thng cac si gan chop xoay ngi thieu kinh nghiem. oi vi nhng ngi mi
trong giai oan cap bao gom au khi ngh ngi va lam sieu am khp vai nhng co kinh nghiem chup
au khi van ong. Sau o, tieng loc coc di mom khp co chat can quang, chung toi e ngh nen
cung xuat hien khi xoay canh tay t the hi a khao sat nhanh bang sieu am trc va sau moi lan
ra trc, va cuoi cung la xay ra yeu tay. Khi chop chup khp co chat can quang . ieu nay cho phep
xoay ton thng, co the gay mat vng khp vai va ho kiem tra kha nang chan oan cua mnh ngay tc
hien tng goi la e ep ben trong se t bieu lo ra. thi. Khi mi bat au, chung toi chup khp co chat
Chom xng canh tay se khong con c gi vng can quang n trc giup chung toi co the khao sat
va co the e ep len mo nam gia chom va mom lai va sa sai trong nhng trng hp chung toi
cung vai. Qua trnh nay se dan en x hoa va tai khong the chan oan ton thng rach cua chop
nh hnh mom cung vai, va tao nen choi doc theo xoay. oi vi nhng ngi khong co kinh nghiem
day chang cung-qua.17 chup khp co chat can quang , co the khao sat sieu
am trong luc mo hay trong phong xac. S quan sat
NHAN XET KY THUAT t m va phau tch trong mo se cho chung ta nhng
bai hoc gia tr nhat. Nhng ngi mi bat au can
Trong y van trc ay, ngi ta s dung sieu am phai nang cao kien thc giai phau, ieu nay rat can
au do sector c hoc vi tan so 5 en 10 MHz e thiet e co ky thuat thanh thao va lam tang kha
sieu am khao sat chop xoay khp vai mot cach nang nghien cu.
hieu qua. Nhng ngay nay au do c hoc nay a Cac moc xng giup hng dan cho viec khao
loi thi. No co nhieu han che bi nhieu yeu to nh sat (Hnh 26-1). Ngi kham dung ngon tay s tm
anh gia vung gan, hep trng quan sat nong, va d mom cung, gai xng ba vai, mom qua va khp
Chop xoay 845
tang phan am, hnh bau duc, nam trong ranh hai
au tren hnh cat ngang. Gan nay i xuyen qua
khoang gia chop xoay va phan chia gan c di
vai vi tren gai. Nen bat au sieu am vi oan gan
au dai gan hai au nam pha tren ranh gan hai
au. oan gan hai au nam trong bao khp se thay
nam chech hn trong bao khp vai. Sau o, khao
sat toan bo ng i cua gan hai au trong ranh hai
au va tiep tuc i xuong cho en cho noi gan c.
Thu thuat nay cho phep phat hien s dch t nhat
trong tui cung hnh tam giac me trong, au xa
cua bao gan. S dch t bao gan hai au nay la
dau ch iem rat nhay cho dch khp. Xoay au do
900 thanh hnh cat doc, se anh gia chac chan tnh
toan ven cua gan hai au. Do au do can than doc
theo ranh hai au (Hnh 26-3). Can phai an nhe
phan di cua au do e gi au do song song vi
gan, tranh anh gia do tnh d hng cua gan.
Sau o, xoay au do tr ve mat cat ngang va di
chuyen len tren doc theo canh tay e thay gan c
di vai, no hien len nh mot dai phan am mc o
va, nam sau ben di lp m va tui hoat dch
di c delta. Quan sat gan c di vai song song
Hnh 26-1. Cac moc giai phau chung. Hnh chup vi truc cua no (Hnh 26-4); khao sat khi xoay
nghieng cho thay cac cau truc xng, chung gii han ca so ngoai thu ong canh tay se giup anh gia s toan
am dung e khao sat chop xoay. Sup, c tren gai va gan, I, c
di vai va gan; au mui ten, gai xng ba vai; mui ten, mom
ven cua gan c di vai, no co the rach nhng
cung; H, xng canh tay. benh nhan b trat khp vai man tnh ra trc. ong
tac xoay ngoai cung rat can thiet e chan oan tnh
trang ban trat cua gan c hai au, ac biet neu ch
cung on. nh hng au do theo cac moc xng hien dien luc co luc khong.20
nay se rat can thiet e quan sat ung ky thuat khi Tui hoat dch di c delta bnh thng c
khao sat benh ly phc tap cua vung vai. Cac moc nhan dang nh mot lp phan am kem, mong gia
xng ben ngoai rat quan trong trong chan oan c delta ve mot pha va cac gan chop xoay, gan c
hnh anh vung vai khi khao sat benh nhan co benh hai au ve pha sau. Lp m quanh tui hoat dch
ly nang va mat cac moc mo mem bnh thng. co phan am tang nam bao quanh mat ngoai cua lp
Benh nhan c sieu am t the ngoi, tren hoat dch.21
ghe khong co tay cam. Ngi lam sieu am ngoi Gan c tren gai c khao sat vuong goc vi
thoai mai tren ghe co banh xe, cao hn benh nhan truc cua no (mat cat ngang) bang cach di chuyen
5 cm e de di chuyen. Neu mi vao nghe, nen sieu au do ra pha sau ngoai. Ca so sieu am rat hep
am tren ca hai vai, bat au tren vai t trieu chng va can phai nh v au do mot cach chnh xac
hn. Ky thuat sau ay c dung tai benh vien cua (Hnh 26-5). Gan c tren gai hien len nh mot dai
chung toi.8 phan am va, sau ben di tui hoat dch di c
Nhng hnh anh cat ngang qua au dai gan hai delta va nong hn lp phan am sang cua be mat
au c thc hien vi canh tay va cang tay e xng cua mau ong ln.
tren ui benh nhan , ban tay sap (Hnh 26 2). Phan con lai cua qua trnh khao sat c thc
Ranh gan hai au la moc giai phau e phan biet hien vi canh tay khep va duoi toi a, vai xoay
gan c di vai vi gan c tren gai. Ranh nay lom; vao trong mc o va5,7,22 (Hnh 26-6). Co the giai
phan am sang phan chieu be mat xng canh tay. thch de hieu nhat t the nay cho benh nhan bang
au dai gan hai au hien len nh mot cau truc cach yeu cau ho e tay ra sau lng va co cham vao
Hnh 26-2. Gan 2 au (cat ngang). A, Hnh lam sang; B, Hnh sieu am gan hai au, B,
la cau truc hnh bau duc phan am tang nam trong ranh hai au (mui ten). C, Hnh cat cung
v tr cho thay gan hai au phan am kem, B, bao quanh pha trc bi dch mot benh nhan
khac co tran dch khp va rach chop xoay,D, c delta; SUB, gan c di vai; mui ten: ranh
hai au. (Trch t Mack LA, Nyberg DA, Matsen FA. Sonographic evaluation of rotator
cuff. Radiol Clin North Am 1998;26:161-177.)
Hnh 26-3. Gan 2 au (cat doc). A. Hnh lam sang. B.

Hnh sieu am gan c hai au, B, chu y gan (mui ten) tr
nen phan am kem gia do goc no tao vi au do lech i
1800. D, gan c delta
Chop xoay 847
Hnh 26-4. Gan c di vai. A, Hnh lam

sang. B, Anh oi cho thay gan di vai, SUB,
song song vi truc cua no (cat doc khi xoay
trong va ngoai) bieu hien nh mot dai phan am
mc o va nam sau di tui hoat dch di c
delta (au mui ten), D, c delta, B, gan hai
au; mui ten, be mat xng canh tay. C va D,
Hnh lam sang va hnh sieu am vuong goc vi
truc gan c di vai, D, c delta; mui ten, gan
hai au; SUB, gan c di vai. (Trch t Mack
LA, Nyberg DA, Matsen FA. Sonographic
evaluation of rotator cuff. Radiol Clin North Am
1998;26:161-177.)
Hnh 26-5. Gan tren gai (cat ngang). A va B: Hnh lam

sang va sieu am gan c tren gai, SUP, la mot dai phan am
va nam di tui hoat dch di c delta (mui ten m). Mui
ten, be mat xng canh tay; D, c delta; HH, chom xng
canh tay. (Trch t Mack LA, Nyberg DA, Matsen FA. anh
gia chop xoay tren sieu am. Radiol Clin North Am
1998;26:161-177.)
xng ba vai ben kia. Chung ta se thay u ca hai mo chim khi no bam vao mat sau mau ong ln
hnh cat doc theo ng i cua gan tren gai, hnh (Hnh 26-7). Xoay trong va ngoai khp vai se giup
cat ngang cho bam cua gan, va hnh vuong goc vi ch rat nhieu trong viec khao sat gan c di gai.
chom xng canh tay. nh hng ung la khi mat Thu thuat nay lam co va duoi gan di gai trong
cat hnh cho thay s ro net cua be mat xng va nhieu kieu khac nhau. v tr nay, quan sat c
ng vien sac net cua sun chom xng canh tay. mot phan sun vien o chao pha sau nh mot cau
Trong luc cat hnh doc, au do se nam tren mom truc hnh tam giac, phan am manh. Dch cua gan
cung ben trong va mat ngoai cua mau ong ln di gai nam xung quanh sun vien. Sun khp phan
ben ngoai. au do quet tron xung quanh chom am kem cua chom xng canh tay, pha ngoai sun
xng canh tay; nen gi au do thang goc vi be vien, tng phan ro net vi phan am manh cua sun
mat chom xng canh tay moi thi iem. ong si. Khao sat i tiep vao trong bao quat ho gai-o
tac quet nay bat au t gan c tren gai pha trc chao va than kinh, mach mau tren vai. au do
en gan dai c hai au; chung ta se khao sat bao ang hng nam ngang c di chuyen xuong di
quat mot vung khoang 2,5 cm pha ngoai gan dai va se quan sat thay gan c tron nho. C tron nho
c hai au. Gan di gai c khao sat ben di co cau truc hnh thang (Hnh 26-8). No khac biet
iem moc nay. Cho noi gan c cho thay c phan vi gan di gai bi no rong hn va co c bam
am giam bao xung quanh gan c di gai phan am nhieu hn. Rat hiem khi rach gan nay, va chung toi
tang. Mat cat ngang bat au ngay pha ngoai mom cha thay rach gan tron nho n thuan trong 6.000
cung va i xuong tren gan c tren gai va mau ong khp vai co trieu chng c sieu am. Mac du vay,
ln. Vung nguy hiem la phan gan bat au t chung toi van khao sat vung nay e t am bao
khoang 1 cm sau ngoai gan c hai au. Khong rang gan di gai c khao sat ay u. v tr
quan sat ay u vung nay co the gay ket qua am nay, cung co the de dang thay c dch khp
tnh gia.5 lng t.23 ieu nay giup phan biet cac benh ly
Sau khi khao sat gan tren gai, chung ta se khao khp nh viem khp dang thap va viem khp
sat tiep gan c di gai va gan c tron nho bang nhiem trung, la nguyen nhan gay dch. Trong
cach di chuyen au do ra sau va theo mat phang benh ly chop xoay hiem khi thay dch v tr nay.
song song vi gai xng ba vai. Gan c di gai Hnh cat mat phang tran qua khp cung on
bieu hien di dang mot cau truc mo mem hnh c thc hien cuoi cung. So sanh ben trai va ben
Chop xoay 849
Hnh 26-6. Gan tren gai. A, V tr au do vi canh tay duoi va xoay trong. B, Hai hnh cat doc
gan c tren gai vi canh tay trung tnh va duoi vi tay xoay trong cho thay quan sat gan c tren gai de
hn (mui ten).
Hnh 26-7. Gan di gai. A, Hnh lam sang. B, Anh oi gan c di gai, INF, khi xoay
trong INT, va xoay ngoai,EXT. Mui ten en, gai vai, mui ten trang, be mat xng canh tay. D,
c delta; au mui ten, sun vien o chao pha sau. (Trch t Mack LA, Nyberg DA, Matsen FA.
Sonographic evaluation of rotator cuff. Radiol Clin North Am 1998;26:161-177.)
Chop xoay 851
dch nay co nhieu iem tng ong nh: la mot

khoang ao (co the cang phong len khi dch), co
lp dch boi trn mong trong long cua no va co
mang li mao mach va mach bach huyet phong
phu vach. Cac mach nay khong the thay tren
sieu am Doppler mau oi vi benh nhan co giai
phau chop xoay bnh thng, nhng thay c tren
sieu am Doppler mau nang lng benh nhan co
chop xoay b viem.24 Gia tui hoat dch va c delta
co cha mot lp m quanh tui hoat dch. Lp nay
co phan am kem va o day cua no rat ong nhat;
the trang dng nh t anh hng len o day cua
lp m nay.
Benh ly chop xoay hiem gap benh nhan tre
Hnh 26-8. C tron nho. C tron nho, TM, thay di dang tuoi. Benh ly sun vien va bao hoat dch co the xay
cau truc hnh thang. Mui ten, xng canh tay. D, c delta. ra. Mot so benh ly nay co the co bieu hien giong
(Trch t Mack LA, Nyberg DA, Matsen FA. Sonographic nh rach gan. chung ta can phai biet rang chop
evaluation of rotator cuff. Radiol Clin North Am 1998;26:161-
xoay ngi trng thanh cha nhieu c hn
177.)
ngi co tuoi. Chieu dai tng oi cua gan so vi
phai se tm ra benh ly do thoai hoa hoac chan c tang len theo tuoi.25 Nhng vung phan am kem
thng, ma bat chc hoac gay ra nhng trieu chop xoay cua benh nhan di 20 tuoi co the n
chng giong nh b e ep. Sun vien o chao tren co gian chnh la c, va nhng dau hieu nay khong
the thay vi au do gi thang t pha sau khp c de dang ket luan la rach gan.
cung on va hng vuong goc vi o chao tren. Co
the phai can dung au do linear array cong neu Cac bien oi lien quan en tuoi tac
ngh nhieu en chan oan troc sun vien pha tren Chop xoay nhng ngi di 30 tuoi th vng
(ton thng SLAP) chac. Hnh khp co chat can quang cho thay khong
co s thong thng vi tui hoat dch di mom
CHOP XOAY BNH THNG cung-di c delta.18 Cac nghien cu tren xac va
ngi mi chet cho thay co ty le cao rach chop
Chop xoay ngi trng thanh xoay nhng ngi ln tuoi. Keyes26 khao sat
Cac gan chop xoay co phan am manh hn so vi ngau nhien 73 xac chet va thay rach toan bo be
bung c delta (Hnh 26-6). Cac gan chop xoay c day gan tren gai chiem 13,4%, khong thay rach
boc trong mot lp hoat dch mong ma bnh thng toan bo be day nhng ngi tre hn 50 tuoi, tan
nho hn 1,5 mm va co phan am kem hn gan. o suat mac phai cho ngi tren 50 tuoi la 31%.
day cua lp hoat dch nay khong thay oi; tui hoat Wilson va Duff27 a khao sat ngau nhien 74 ngi
dch di mom cung-di c delta pha tren gan mi chet va 34 xac phau tch tren 30 tuoi. Ho thay
dai c hai au day tng t nh pha tren gan c rach toan bo be day gan tren gai la 11% va ban
di vai, tren gai va di gai. Khao sat ung, se phan la 10% cua cac vai khao sat. Fukuda va cs.28
thay c tui hoat dch hnh dang gon gang nh bao cao ty le rach toan phan la 7% va ban phan la
mot dai phan am kem, mong hn be day cua sun 13% khi nghien cu tren xac ma khong quan tam
hyalin phan am kem cua chom xng canh tay. Tui en tuoi tac. Vi tan suat cao rach chop xoay nh
hoat dch ngoai khp nay la mot khoang ao, no the khi nghien cu tren xac th co bao nhieu trng
cha hoat dch boi trn, chat dch nay khong the hp rach chop xoay ma khong co trieu chng? Mot
phan biet c neu sieu am khp vai thng qui. nghien cu cua chung toi gan ay cho thay sieu
Tui hoat dch nay co hnh mong bo khi cat ngang, am co the phat hien cac trng hp rach chop
va no thng trai rong t mom qua pha trc, bao xoay khong trieu chng.
xung quanh pha ngoai khp vai va bang qua o Chn mi ngi tnh nguyen (47 n va 43
chao pha sau. Khoang mang phoi va khoang hoat nam) trong mot quan the ma khong c canh bao
Hnh 26-9. T le phan tram cac khp vai co rach chop xoay nhng ngi
trng thanh khong co trieu chng cac nhom tuoi khac nhau. Bieu o cho
thay s so sanh gia tay thuan va tay khong thuan
trc ve benh ly vung vai c cho sieu am khp hai ben. Ngi tre nhat rach ban phan la 35 tuoi,
vai; 77% (69/90) la ngi da trang capcaz, 13% ngi tre nhat rach toan phan la 54 tuoi. Tuoi trung
(12/90) la ngi My goc Phi, 9% (8/90) la ngi bnh cua rach ban phan la 35 en 80. tuoi trung
chau A, va 1% (1/90) la Tay Ban Nha va Bo ao bnh cua rach toan phan la 54 en 92. Tuoi trung
Nha. 18 ngi thuoc nhom tuoi 40 en 49; 18 thuoc bnh cua nhom rach ban phan la 56. Tuoi trung
nhom 50 en 59; 13 thuoc nhom 60 en 69, 13 bnh trong nhom rach toan phan la 63.
thuoc nhom 70 en 79 va 10 ngi thuoc nhom 80 Trong 19 trng hp (46%), rach chop xoay co
en 99 tuoi. Ty le nam n gan nh bang nhau trong kem theo hoat dch. Trong 15 trng hp, dch
tng nhom tuoi. trong bao gan hai au va trong 4 trng hp con lai
Khong co s khac biet co y ngha thong ke ve dch trong tui hoat dch di mom cung-di c
tan suat cua cac ton thng chop xoay trong moi delta. Co hai trng hp co rach chop xoay, dch
gii cho tay thuan va khong thuan (Hnh 26-9). trong bao gan hai au va ca tui hoat dch. dch
Chung toi cung khong ghi nhan c s khac biet gan di gai la bnh thng trong tat ca benh nhan.
co y ngha thong ke nao ve ty le ton thng chop Mi mot trng hp dch c ghi nhan trong
xoay lien quan en gii tnh hay mc o cac hoat bao gan hai au cua nhng ngi khong rach chop
ong gang sc ghi nhan c. Nhng tan suat rach xoay. Khong bao gi dch trong tui hoat dch di
chop xoay ca hai tay thuan va khong thuan cho cung-di c delta neu chop xoay khong b rach.
thay s gia tang tnh tien sau tuoi 40. S khac biet S bao mon nong hay khong eu cua mat xng
nay rat ang ke ve mat thong ke gia cac tuoi thap di cho rach c ghi nhan trong 90% cac trng
nien 30, 40, 50 va gia hn. Ty le phan tram tong hp rach, nhng thay oi ve xng hien dien trong
cong cua rach chop xoay toan phan va ban phan tat ca trng hp rach ngoai tr 4 trng hp rach
xap x 33% gia tuoi 50 va 59, 55% gia tuoi 60 va ban phan. Trong nghien cu nay, gap mau ong
69, 70% gia tuoi 70 va 79, va len en 78% tren ln khong eu trong 37 khp vai hay 21%. Mau
tuoi 80 (xem bieu o 26-9, 26-10). ong ln khong eu gap mi hai khp vai
Chung toi ghi nhan tong cong 26 trng hp khong rach chop xoay. Co s tng quan co y
rach toan phan, va 15 trng hp rach ban phan, 16 ngha thong ke gia rach chop xoay khong trieu
trng hp hay 64% benh nhan b rach chop xoay chng va s khong eu cua mau ong ln
Chop xoay 853
Hnh 26-10. Bieu o cho thay tan suat giai oan 1 en 3 cua hoi
chng e ep tay thuan cua cac nhom tuoi khac nhau. Nhng bat
thng vung di mom cung c phan giai oan tren sieu am nh sau: giai
oan 1 neu be day tui hoat dch 1,5 - 2 mm; giai oan 2 neu be day tui hoat dch
hn 2 mm; giai oan 3 neu rach chop xoay toan phan hay ban phan be day.
mau ong ln.

Ket qua cua chung toi cho thay rang dau hieu
bat thng chop xoay hay dch bao gan 2 au co
the tng hp vi s c ong bnh thng va khong
au cua khp vai. Can can than ly giai cac ket qua
tm thay chop xoay oi vi trng hp tren 50
tuoi. Rach chop xoay khong nhat thiet la nguyen
nhan gay au khp vai ngi ln tuoi, va ch co
the la mot phat hien tnh c. Cac thay oi chop
xoay do thoai hoa co the c xem nh la s tng
quan t nhien do lao hoa, tang tnh tien co y ngha
thong ke sau tuoi nam mi cua cuoc song. Can
Hnh 26-11. Rach chop xoay toan phan khong trieu
phai da tren chan oan lam sang e phan biet
chng. Hnh cat doc qua gan c tren gai, ss, cho thay s rut lai
cua mo (cac dau thap). Be mat xng cua mau ong ln, gt, b
rach chop xoay co trieu chng va khong co trieu
lot tran khong eu. Tui hoat dch di c delta, b, ay dch. D, chng. Mat khac, viec tm thay rach chop xoay
c delta. khong nen lam nha lam sang ngng tm nguyen
nhan khac gay au khp vai. Viec oc ket qua
sieu am khp vai cua chung toi c thc hien
(Hnh 26-11). phoi hp vi viec oc ket qua anh gia X quang
Hai mi trng hp rach toan phan be day khp vai ban au. Bang khao sat can than nay,
c coi la rong va anh hng len nhieu gan. Co chung toi a phat hien ra khong t cac ton thng u
ba trng hp rach rat rong, ng knh 4cm, va tan sinh xng nguyen phat va th phat, u tuy, hay
ba trng hp rach nho 2cm be ngang khi o bu Pancoast b bo sot. Han che c ong va au
ay mau ong ln. khi gi tay cao co the la do nhieu benh ly, trong o
Mi trng hp rach ban phan co phan am benh ly chop xoay la thng gap nhat. Theo kinh
hon hp va nam trng hp phan am kem. Chn nghiem cua chung toi, rach chop xoay toan bo be
ton thng co phan am hon hp va hai trng hp day xay ra ong thi vi mot khoi u vai hay xung
rach phan am kem the hien thay oi xng cua quanh vai khong phai la hiem gap.
khiem dien khu tru gan c tren gai, hay hiem gap
TIEU CHUAN RACH CHOP XOAY hn la khiem dien khu tru gan c di vai. Kieu
rach thng gap nhat gay ra do benh ly tai cho noi
Khong thay chop xoay gan-xng. Gan se troc khoi be mat xng va e
Khong thay mot phan chop xoay lo mot vung xng tran (Hnh 26-14). Trc ay,
Mat lien tuc trieu chng nay c goi la dau hieu mau ong
Phan am bat thng khu tru ln tran trui. Be mat xng mau ong ln va co
giai phau xng canh tay bat thng trong khoang
79% cac ton thng rach nay. Phan ln nhng ton
thng rach nh vay se xay ra phia trc gan c
tren gai va vung nguy hiem. ien hnh, se con
CAC BIEU HIEN TRC MO mot t mo bao quanh gan hai au. Ly tng nhat,
nhng loai rach nay co the c xac nh trong hai
Tieu chuan cua rach chop xoay mat cat sieu am vuong goc nhau. oi khi khong
Cac tieu chuan ve sieu am c cong bo trc ay the thc hien ieu nay c v lo rach co the thay
ve benh ly chop xoay c sap xep vao bon rach toan bo be day mat cat nay nhng khong
nhom29: khong thay chop xoay, khong thay mot xac nh c nh vay mat cat vuong goc. Hien
phan chop xoay hoac khiem dien khu tru cua chop tng nay c cho la c lng trung bnh the tch
xoay, mat lien tuc, va phan am bat thng khu tru. mot phan nhng lo rach nho hn be mat au do.
Khong thay chop xoay. Chom xng canh Lo rach nho nam ngang ien hnh xuat hien tren
tay tiep xuc trc tiep vi mom cung la mot dau hnh cat doc nhng co the bo sot tren hnh cat
hieu noi len co rach chop xoay rong. Trong trng ngang. Dau hieu giup ch la mo hoat dch va m
hp nay, sieu am thay c delta phu trc tiep len quanh hoat dch cuon vao trong cho khuyet
nh chom xng canh tay (Hnh 26-12). Trong mot khu tru. Vi mot so t ngoai le, hnh anh cuon nay
vai trng hp tui hoat dch day len va se thay lp la mot dau hieu cua rach toan bo be day. Neu rach
m nam gia c delta va be mat chom xng canh rong hn, mo hoat dch va m quanh hoat dch se
tay. Lp mo nay co phan am kem hn va co cau hien dien gan sat vi be mat xng (xem Hnh 26-
truc loang lo. Be day cua lp nay phu thuoc vao v 14).
tr cho rach, nhng nhn chung, no mong hn va Khong nen nham lan hnh anh khiem dien khu
khong eu hn so vi lp chop xoay bnh thng. tru vi hnh anh mong i mot oan cua chop
Mot vai tui hoat dch co the day en 5 mm. oi xoay sau phau thuat chop xoay. Hien tng mong
vi ngi sieu am cha co kinh nghiem, co the lam i nay la bnh thng sau hau het cac thu thuat
lan lp hoat dch nay vi chop xoay bnh thng. nh lai gan-xng. Trong nhng trng hp nay,
oi vi nhng vet rach rong len en 4 cm, chom ranh xng se hien len di dang cho khuyet hnh
xng canh tay co the i len qua cho rach do lc ch V hoac hnh tron ng vien chom xng
keo cua c delta. Gan c tren gai b keo tut vao canh tay. Gan c keo xuong trong ranh hep nay.
di mom cung, va tren nguyen tac, khong the Gan khong c nh lai vao mau ong ln nh
phau thuat nh lai trong giai oan nay (Hnh 26- giai phau hoc vi cho bam rong ma ch vi au
13). Phai ghi nhan lai mc o rach v thng b anh gan thon nho hn. Ai cung biet rang nhieu trng
hng nhieu gan. Chan oan nhng ton thng hp tao hnh nh vay khong the chac chan ngay ca
rach rong nay co the thc hien trc nh chup khi phau thuat thanh cong. Cho rach tren bao khp
Xquang khp vai. Mot vai ni dung X quang co se gay mong them tai cho. mot benh nhan ma
hnh anh so sanh luc dang vai chu ong hay hnh khong c nghien cu chuan mc, cho rach lai se
nam nga chup trc sau cua khoang di mom c xac nh bi viec quan sat thay dch co phan
cung e chong lai lc keo cua trong lng tren am trong r ra qua cho rach.
xng canh tay.30 Theo nguyen tac, khoang di Mat lien tuc chop xoay. Thuat ng nay c
mom cung khong c nho hn 5 mm. dung cho nhng cho rach co v tr gan ve pha gan
Khong thay mot phan chop xoay. Nhng hn. Nhng cho rach nay co khuynh hng kieu
ton thng rach nho hn se bieu hien di dang doc va thng do chan thng gay ra.31 Benh nhan
Chop xoay 855
Hnh 26-12. Khong thay chop xoay. A, Hnh cat ngang, C delta , D, tiep xuc trc tiep vi chom
xng canh tay, H. Mot lp phan am manh (mui ten cong) cua m nam di c delta, lp nay ngan cach
c delta va xng canh tay. B, Hnh cat doc qua v tr thng gap cua gan c tren gai. Khong thay gan c
tren gai. Mot lp m phan am manh (mui ten cong) nam di c delta, D. H, chom xng canh tay.
Hnh 26-13. Rach chop xoay khong may lai c. So

sanh phai-trai tren ng cat doc cho thay o day cua mo mem
khong bang nhau mot cach ro net. Gan c tren gai, ss, bnh thng
vai trai khong co trieu chng , LFT. Gan c tren gai ben phai,
Hnh 26-14. Rach toan phan theo chieu ngang. Hnh
RHT, b keo tuot khong thay c. Noi soi cho thay b rach cua
cat doc qua gan c tren gai, S, cho thay gan rach rut lai 2cm
gan c tren gai b keo ra xa o chao. Cho rach chop xoay c coi
(khoang cach gia hai dau thap). Tui hoat dch va m quanh
la khong the may lai c.
tui hoat dch (mui ten cong) nam trc tiep tren be mat xng
khong eu cua mau ong ln, gt. E, au xng canh tay.
Hnh 26-15. Rach toan phan theo chieu doc. Hnh cat
ngang qua gan c tren gai, S, cho thay vung phan am trong, mat
lien tuc trong lp chop xoay. Sun chom canh tay c boc bi
mot ng vien sang, va c goi la dau hieu ng vien sun
CAC DAU HIEU KEM THEO TRONG

RACH CHOP XOAY
dch tui hoat dch di c delta.

dch khp
ng vien m di c delta b lom Hnh 26-16. S mat lien tuc cua chop xoay. Hnh cat
Be mat xng mat eu an. ngang gan c tren gai, sup, trong: A, v tr trung tnh va B, canh
tay duoi, xoay trong cho thay mot lo rach nho cha ay dch
(au mui ten). Chu y ch thay rach khi canh tay duoi. D, c
delta; mui ten: tui hoat dch di c delta.
co the co tien can trat khp vai trc o. S mat chop xoay b bat thng lan toa hoac khu tru. Bat
lien tuc quan sat thay khi co cho khuyet nho lap thng lan toa ve phan am cua chop xoay a c
ay dch khp hay mo phan ng co phan am kem chng minh la dau hieu sieu am khong ang tin
(Hnh 26-15). Cac ton thng nh vay thng noi cay cho rach chop xoay.
bat hn khi e canh tay t the duoi va xoay trong Phan am bat thng khu tru i kem vi ton
(Hnh 26-16). Thng cung co mot lng t dch thng rach nho toan bo hay ban phan be day. Mot
bao hoat dch. Ngi sieu am co the s dung dch vung tang phan am co the la mot ng mi ben
nay nh mot vat trung gian tng phan t nhien e trong gan tai v tr ton thng si, khi quan sat thay
bieu lo cho rach chi tiet hn. Dung tay an len tui trong mot vai trng hp rach ban phan be day.
hoat dch di c delta lam di chuyen dch t cho Ton thng nho phan am manh co hnh dau phay
rach vao trong khp. Thu thuat nay giup quan sat hoac ng thang, thng c bao quanh bi phu
cho rach ro rang hn. Hnh anh mot giao dien sang hoac dch, va bieu hien nh mot quang phan am
khu tru xung quanh mot oan sun hyaline va sau kem (Hnh 26-17). Ton thng rach ban phan giong
xuong tan gan co phan am kem c coi la mot nh lo rach co vien(rim rents), c Codman9
dau hieu cua rach toan bo be day (Hnh 26-15). quan sat thay au tien ve mat benh hoc. Mot kieu
Dau hieu nay a c at ten la dau giao dien- hi khac cua rach ban phan be day co the hien th
sun trong mot bao cao trc o.31 nh mot om phan am trong tren mat khp hoac
Phan am bat thng khu tru. Phan am cua mat tui hoat dch cua gan.8 Can khao sat can than
Chop xoay 857
Hnh 26-18. O phan am bat thng. A, Hnh cat doc gan c tren gai cua mot lo rach ban phan pha be mat khp c goi la
lo rach co vien. Mot sang thng phan am manh dang ng thang trong gan c tren gai (mui ten m) c bao boc xung quanh
bi mo phu ne phan am kem (mui ten cong). B, Hnh cat ngang gan c tren gai cho thay cho khuyet ban phan be day tng t. Ghi
nhan ton thng tng t tang phan am .
Hnh 26-18. Phan am bat thng khu tru mot lo rach co vien phan am kem. A, Hnh cat doc gan tren gai cua mot
lo rach ban phan pha be mat khp. Mot sang thng phan am kem (mui ten cong) nam sau trong gan tren gai. Be mat xng
khong eu (mui ten) va co mot lng nho dch (mui ten m) trong tui hoat dch di c delta. B, Hnh cat ngang gan tren gai cua
cung mot lo rach ban phan (gia hai dau thap). Mot lp mo con nguyen ven (dau hoa th) phu be mat tui hoat dch cua lo rach. Be
mat xng khong eu (mui ten).
cac be mat hoat dch cua gan. Ch co nhng khiem Cac dau hieu kem theo
khuyet phan am kem khu tru nh the tren be mat dch tui hoat dch di c delta. Viec
mi co the c coi la rach (Hnh 26-18). Cac ton quan sat thay dch tui hoat dch di c delta la
thng ben trong gan la loai thng gap nhat cua dau hieu kem theo ang tin cay nhat cua rach chop
cac ton thng ban phan va chiem gan nh 50% xoay (Hnh 26-19). Dau hieu nay tm thay trong ca
cac khiem khuyet. Chung toi khong goi chung la rach toan phan va ban phan be day. Lp dch phan
rach v chung khong c cac phau thuat vien coi am trong khac vi hien tng phu phan am kem
la rach, ho khong the nhn thay chung bang quan cua hoat dch. Phu la dau hieu thng gap trong
sat trc tiep tren gan. ieu nay gay nen mot van hoi chng e ep vai nhng ch hiem khi kem theo
e ve chan oan tng t nh ton thng ben trong vi rach. Phu va dch co the phan biet lan nhau
sun chem khi chup MRI. Cac dau hieu cua hoat nh thu thuat ep au do. Tui cung hoat dch ay
dch hay xng kem theo co the giup ch neu hnh dch se trong khi e ep, tui cung vi phu mo hoat
anh sieu am khong ang tin cay. dch ch thay oi hnh dang chut t. Cac nguyen
Hnh 26-19. dch tui hoat dch di c delta. Hnh

cat doc cua gan c tren gai, SUP, vi au do at pha ngoai
cho thay t dch tui hoat dch di c delta, F. Mui ten, tui
hoat dch di c delta. GT, mau ong ln.
nhan khac tao dch trong tui hoat dch la: sa calci
trong viem mo hoat dch va viem tui hoat dch do
vi trung. Hollister va cs. a tm thay s hien dien
tren sieu am cua dch tui hoat dch co o chuyen
biet en 96% trong chan oan rach chop xoay. Ket
qua tng t cung c Farin va cs. tm thay.
Trong nghien cu tien cu cua chung toi ve benh
ly chop xoay, tat ca cac benh nhan co dch trong
tui hoat dch eu co rach chop xoay.
Tran dch trong khp. Dch khp co the tm
thay trong tui cung cua khp, bao gom: tui cung
nach, di mom qua va di gai. benh nhan co
t the ngoi thang, hau het dch se tch tu trong bao Hnh 26-20. Hnh anh tren sieu am cua chop xoay a
gan hai au. Khoang phan na cac trng hp mo. A, Hnh ve minh hoa ky thuat nh lai chop xoay vi tao
dch nay i kem vi rach chop xoay. Phan na con mot ranh (mui ten) tren chom xng canh tay, nh phan gan
lai la do nhieu nguyen nhan khac khp cua benh con lai vao ranh, va ky thuat may nh lai ac trng. B, Gan c
ly khp vai. Khi tm thay tu dch nhieu tui cung tren gai cat doc SUP, cho thay hnh anh ac biet cua ranh tai
tao (mui ten). Cho mat do cat mom cung (mui ten m) cung
gan di gai ma khong thay dch tui hoat dch thay c. GT, mau ong ln; mui ten cong, ch may, D, c
di c delta, se chac chan loai tr c nguyen delta.
nhan viem hoac nhiem trung cua benh ly khp.
Lom ng vien m di c delta. benh trong trong rach chop xoay. Phan ln rach toan bo
nhan bnh thng, ng phan am sang t lp m va ban phan 1 cm phan xa cua chop xoay se i
di c delta se loi len tren. Co the thay ng kem vi cac gai xng nho va cac hoc be mat
vien di c delta b lom trong rach va va rong, xng cua mau ong ln. Viec dung au do tan so
phan anh s khiem dien cua gan chop xoay. Co the cao e khao sat rach chop xoay co the lam ro hn
ep sat c delta len be mat chom xng canh tay cac dau hieu nay. S bat thng cua mau ong se
ngay ca nhng lo rach nho bang cach dung thu phu hp vi bat thng cua gan ve v tr, kch
thuat ep au do tai v tr rach. thc va hnh dang. Nguyen nhan cua s bat
Be mat xng mat eu an. Ch mi gan thng nay van cha c biet. Chan thng do va
ay, dau hieu mat eu an cua xng mi c coi cham cua mau ong ln vi mom cung khi gi tay
la mot dau hieu kem theo thng gap va quan qua au a c nghien cu.
Chop xoay 859
Hnh 26-21. Chop xoay sau mo tam quan trong cua viec khao sat khi
duoi canh tay. A, Hnh cat doc gan tren gai v tr chuan cua mot benh nhan sau mo
may rach chop xoay toan phan cho thay ranh tai tao, nhng khong thay bang chng cua
gan c tren gai, lam ngh en rach lai. B, Hnh sieu am vi tay duoi va xoay trong cho
thay cho may con nguyen. Gan c tren gai con lai, SUP, b mong i. Chu y khong thay o
phan am sang ac trng cua tui hoat dch di c delta (au mui ten). Mui ten, ranh tai
tao; GT, mau ong ln. AS, bong lng mom cung, D, c delta
CAC BIEU HIEN SAU MO Cac bieu hien tren sieu am cua cac gan chop
xoay khong bao gi tr ve bnh thng benh
Cac bao cao gan ay trong y van cho rang sieu am nhan sau mo. Cac gan, ac biet la gan tren gai,
ong mot vai tro quan trong trong viec theo doi thng co phan am va mong khi so vi vai oi
hau phau chop xoay. V cuoc mo co the bien oi ben. dch khp thng gap va nhn ro nhat doc
cac moc sieu am, nen sieu am tren benh nhan sau theo gan hai au. V viec lay i lp hoat dch di
mo se kho khan hn trc mo. Do o, ieu quan c delta a lam mat mot moc quan trong, nen sieu
trong la phai hieu ro qua trnh phau thuat c am ong ac biet quan trong e phan biet chop
dung trong tao hnh mom cung va chop xoay. xoay phan am kem, mong vi c delta xung quanh.
Trong tao hnh mom cung, ngi ta cat bo mat
trc di cua mom cung. Tren sieu am, se thay Rach lai chop xoay
mat ng vien phang, tron bnh thng cua mom Tren sieu am, cac ton thng rach tai phat thng
cung. Sau mo, mom cung tr nen nhon (Hnh 26- bieu hien nhat di dang khiem dien chop xoay.
20). V mat di cua mom cung c lay bo, nen Dch lap ay cho khuyet tren chop xoay a may
co the quan sat thay gan c tren gai rong hn. hay ch long leo la nhng dau ch iem khac cua
Phau thuat tao hnh chop xoay tao nen cac hien tng rach lai (Hnh 26-22). Tr phi sieu am
moc sieu am ac biet. Gan chop xoay c nh c ban c thc hien trong thi iem sau mo, rat
lai trong ranh, c tao vuong goc vi truc gan kho phan biet lo rach lai nho vi nhng bieu hien
tren gai. Ranh nay nam tren chom xng canh tay tao nen khi ch co mot phan nho cua gan chop
mot v tr sao cho tao c lc cang gan toi u. xoay c nh lai. Gan mong i khong c coi la
Tren sieu am, ranh c tai tao bieu hien nh mot mot tieu chuan, va b xng khong eu luon co
cho khuyet tren ng vien cua chom xng canh nhng benh nhan sau mo. Rach lai rat pho bien.
tay, thay ro nhat vi au do nam doc truc gan tren Chung xay ra en 40% benh nhan co lo rach nho
gai (Hnh 26-20). Ch may se thay nam sau trong c may lai va 80% benh nhan co lo rach ln
ranh, co phan am lap lanh. Can phai sieu am canh trc mo.
tay trong t the duoi va xoay trong e khao sat v
tr nh lai cua gan chop xoay, ac biet khi v tr BAY NGAM
nay pha trong (Hnh 26-21). Khong quan sat
c v tr nay se dan en chan oan dng tnh nh v au do khong ung la nhng loi thng
gia. Tuy nhien, thu thuat nay can phai c thc gap nhat khi sieu am chop xoay. No co the tao ra
hien can than, ac biet ngay sau mo e tranh lam ket qua dng tnh gia va am tnh gia. Th du nh
ton thng lai gan mi nh, rat de rach. sieu am gan c tren gai theo mat phang ngang vi
Hnh 26-22. Rach lai khao sat bang sieu am

sau mo. Hnh cat doc theo c delta trong vung co ranh
tai tao (mui ten). Mot mui ch long leo (mui ten nho) ben
trong tui hoat dch di c delta b dch. au tren xng
canh tay co hnh dang tron bat thng. Co giai phau bien
mat.
Hnh 26-23. Cac bien oi anh gia trong o phan am cua gan. A va
B hai hnh cua cung mot gan tren gai cho thay khac biet ro net trong o phan
am co the tao c anh gia do v tr va hng au do.
au do at pha ngoai co the gia anh mot ton quan he hnh hoc cua gan va au do. Theo Grass
thng rach chop xoay. mot hnh mat cat ngang va cs., va Fornage mo ta, viec khong the hng
chech cua gan tren gai co the c oc lam la au do song song vi th si cua gan se tao nen
mong chop xoay. Do o, ngi lam sieu am phai vung giam am gia (Hnh 26-23). Khi ch mot vung
khao sat chop xoay trong hai mat phang vuong nho cua gan song song vi au do, se tao ra mot o
goc. Viec nhn thay ng vien xng ro net se tang am, gia anh mot ton thng rach nho toan bo
giup tranh nhng bay ngam nay. hay mot phan be day. Anh gia nay ac biet de
Mot nguyen nhan khong ong nhat cua gan la nhan ra vi au do sector.
Chop xoay 861
THAM KHAO 20. Farin PU, Jaroma H, Harju A et al. Medial displacement of
1. Matsen FA, Arntz CT. Subacromial impingement. In: the biceps brachii tendon: evaluation with dynamic sonography
Rockwood CA, Matsen FA III, eds. The Shoulder. Vol H. during maximal external rotation. Radiology- 1995;195:84a.
Philadelphia: W.B. Saunders Co; 1990. 21. van Holsbeeck M, Strouse PJ. Sonography of the
2. Neviaser RJ, Neviaser TJ. Observations on impingement. shoulder: evaluation of the subacromial-subdeltoid bursa. AJR
Clin Orthop 1990:254:60-63. 1993; 160:561-564.
3. Resnick D. Shoulder arthrography. Radiol Clin North Am 22. Crass JR, Craig EV, Feinberg SB. The hyperextended
1981;19:243-252. internal rotation view in rotator cuff ultrasound. J Clin
4. Mack LA, Matsen FA, Kilcoyne JF et al. Ultrasound Ultrasound 1987;15 416-420.
evaluation of the rotator cuff. Radiology 1985:157:205-209. 23. van Holsbeeck M, Introcaso J, Hoogmartens M.
5. Mack LA, Cannon MK, Kilcoyne RF et al. Sonographic Sonographic detection and evaluation of shoulder joint
evaluation of the rotator cuff. Accuracy in patients without prior effusion.Radiology 1990;177(P):214.
surgery Clin Orthop 1988;234:21-27. Chop xoay bnh thng
6. Middleton WD, Reinus WR, Totty WF et al. 24. Newman JS, Adier RS, Bude RO et al. Detection of soft
Ultrasonographic evaluation of the rotator and biceps tendon. J tissue hyperemia: value of power Doppler sonography. AJR
Bone Joint Surg 1986: 68:440-450. 1994: 163: 385-389.
7. Crass JR. Craig EV, Feinberg SB. Ultrasonography of rotator 25. Petersson CJ. Ruptures of the supraspinatus tendon.
cuff tears: a review of 500 diagnostic cuffs. J Clin Ultrasound Cadaver dissection. Acta Orthop Scand 1984;55:52-56.
1988;16: 313-327. 26. Keves EE. Observations on rupture of the supraspinatus
8. van Flolshecck MT, Kolowich PA. Fyler WR et al. tendon Ann Surg 1933:97:849-856.
Ultrasounddepiction of partial-thickness tear of the rotator 27. Wilson CL, Duff CL. Patliological study of degeneration
cuff. Radiology 1995:197:443-446. and rupture of the supraspinatus tendon. Ann Surg 1943:47:121-
Nhan xet lam sang 135.
9. Codman EA. The Shoulder. 2nd ed. Boston: Thomas Todd; 1934. 28. Fukuda H. Mikasa M. Yamanaka K. Incomplete thickness
10. DePalma AF. Surgery of the Shoulder. 2nd ed. rotator cuff tears diagnosed by subacromial bursography. Clin
Philadelphia: Lippincott; 1973. Orthop 1987:223:51-58.
11. Refior HJ, Kroedel A. Melzer C. Examinations of the Bieu hien trc mo
pathology of the rotator cuff. Arch Orthop Trauma Surg 29. Middleton WD. Status of rotator cuff sonograpliy. Radiology
1987:106:301-308. 1989: 173:307-309.
12. Milorom C, Schaftler M, Cilbert S et al. Rotator-cuff 30. Bloom RA. Active abduction view: a new maneuver in the
changes in asymptomatic adults. The effect of age.,hand diagnosis of rotator cuff tears. Skeletal Radiol 1991:20:255.
dominance and gender. J Bone Joint Surg 1995;77(B):296-298. 31. van Flolsbeeck M. Introcasco J. Ultrasound of tendons. Patterns
13. Sher JS. Uribe JW, Posada A et al. Abnormal findings on of disease. Instruction Course Lectures l993;47:47o-481.
magnetic resonance images of asymptomatic shoulders. J Bone 32. Hollister MS, Mack LA. Pattern RM et al. Association of
Joint Surg 1995: 77(A):10-15. sonographically detected subacromial/subdeltoid bursal effusion
14. Raven PB. Asymptomatic tears of rotator cuff are and intra-articular fluid with rotator cuff tear. AJR 1995:165:605-
commonplace. Sports MedDig 1995:17:11-12. 608.
15. Miniaci A, Dowdy PA. Willits KR et al. Magnetic 33. Farin PU, Jaroma H, Jarju A et al. Shoulder
resonance imaging evaluation of the rotator cuff tendons in the impingement syndrome: sonographic evaluation. Radiology 1990;
asymptomatic shoulder. Am J Sport Med 1995:23:142-145. 176:845-849.
16. Petterson G. Rupture of the tendon aponeurosis of the
shoulder joint in anterior inferior dislocation. Acta Chir Scand Bieu hien sau mo
Suppl 1942: 77:1-184. 34. Mack LA, Nyberg DA, Malsen FA III et al. Sonography of
17. Neer CS. Anterior acromioplasty for the chronic the post operative shoulder. ,4.fR 1988:150:1089-10')3.
impingement syndrome in the shoulder, a preliminary report. J 35. Crass JR, Craig FV. Feinberg SB. Sonography of tlie
Bone Joint Surg-1972;54A:41-51. postoperative rotator cuff. AJR 1988:148:561-564.
Cac bay
Ky thuat
36. Crass JB. Van de Vegte GL, Harkavy LA. Tendon
18. Rakofsky M. Fractional Arthrography of the Shoulder.
echogenicity: ex vivo study. Radiology 1988:169:791-794
Stuttgart: Gustav Fisher; 1987.
37. Fornage BD.The hypocchoic normal tendon: a pitfall.
19. Ptasznik R, Hennessy OF. Abnormalities of the biceps tendon
JUltrasound Med1987;6:19-22.
of the shoulder: sonographic findings. AJR 1995;164:409.
C H N G 2 7
Gan c

Bruno D. Fornage, M.D.
Cac gan c cua cac chi ac biet rat thch hp

D A N B A I e khao sat bang au do sieu am tan so cao (7,5
en 13 MHz) hoac rat cao (15 en 20 MHz) do
GIAI PHAU
chung nam nong. Phan ln cac benh ly gan eu
KY THUAT KHAO SAT
lien quan en chan thng va viem, va lien quan
HNH ANH SIEU AM BNH THNG
en cac hoat ong the thao hay nghe nghiep ma co
Vai
s s dung gan qua mc, phan ln la do cang qua
Khuyu
Ban tay va co tay
mc hoac do chan thng lap i lap lai.
Goi
Ban chan va co chan GIAI PHAU
BENH HOC
Rach Gan c tao thanh t mo lien ket chac va cc
Rach hoan toan ky ben vi lc keo. Cac si collagen xep day ac
Rach khong hoan toan cach nhau bi mot lng nho chat nen vi mot t
Viem nguyen bao si dai va c xep thanh bo song
Viem gan c song vi nhau. Mang gan la mot lp lien ket long
Viem mang gan leo bao boc xung quanh gan va tao cac vach noi
Viem bao gan gan gia cac bo si collagen.
Viem tui hoat dch Tai cho noi gan c, co mot s an nhau gia
Benh sun xng ngoai khp cac si c va cac si collagen. Ni gan bam vao
Cac hnh thai sau mo
xng luon b voi hoa ang ke va ac trng bi s
U va gia u
co mat cua mo sun. Gan luon bam vao cac mau
SO SANH SIEU AM VI CAC PHNG
ong, gai, mau chuyen, mom hay mao.
PHAP CHAN OAN HNH ANH KHAC
Mau nuoi gan rat ngheo nan, va s trao oi
chat dinh dng xay ra phan ln thong qua chat
nen. Theo tuoi tac, mot khoi lng chat nen va so
lng nguyen bao si se b giam sut, va so lng
si va khoi lng m gia cac gan tang len.
Tai mot so vung co s cang c hoc nao o, gan thng phan chong hnh se khong chnh xac. Mot
c gia co bi nhng cau truc nang c hoc la chon khac la s dung au do tan so thap hn
hoac bao ve. Bao si gi cho mot so gan nam sat (nh 5 MHz) vi trng quan sat rong hn. Gan
xng va giup gan khoi b hien tng cang day ay, phan mem x ly hnh anh c phat trien
cung; th du mac gi gan gap va duoi tai co tay, nham cung cap trng nhn cua sieu am hien th
bao si cua gan gap trong ngon tay, va mac gi tc th, au do array thang c trai rong en 50cm
gan gap va mac mat ngoai ban chan. Cac xng bang cach ch keo au do theo kieu giong nh quet
vng co tac dung lam gia co sc manh cua mot ket hp c dung trong thap nien 1970. Bang
gan. Bao hoat dch co cau truc hnh ong hai vach, cach tao c mot trng nhn bao quat cac cau
bao quanh mot so gan; vach trong cua bao tiep xuc truc c khao sat, ky thuat mi nay a loai bo
sat vi gan. Hai vach nay noi lai vi nhau hai c han che lau i cua sieu am thi gian thc
au. Mot lng hoat dch toi thieu cho phep gan (Hnh 27-1).
trt nhe nhang ben trong bao hoat dch. Tui cung Mot tam em rat co ch giup at cac gan nam
hoat dch la nhng tui nho cha ay dch, tm thay rat nong (nh gan duoi ngon tay mat lng ban
nhng v tr ac biet va hoat ong nh nhng ong tay) ri vao vung hoi tu tot nhat va giup quan sat
ho tr vai tro cua gan. cac gan vung co be mat khong bang phang. Khi
dung tam em, can phai can than gi chum tia sieu
KY THUAT KHAO SAT am vuong goc tuyet oi vi vung khao sat e tranh
tao anh gia.3
Do trng quan sat rong hn va o phan giai tot S phoi hp gia hnh cat ngang va doc se tao
hn trong trng quan sat gan, au do ien t array ra s tiep can ba chieu cho viec khao sat gan. Mot
thang la la chon tot nhat e sieu am gan; nhng s tham khao co gia tr cho giai phau bnh thng
anh gia ang chu y do chech tia sieu am so vi si cua vung khao sat la quan sat vung tng t
gan c tao bi au do sector phased array hay c vung hoac chi oi ben, luon nh rang co rat t kha
hoc va au do array cong, ngoai tr phan trung tam nang gan ca hai ben eu b benh ly.
cua au do. Se at c hnh anh co o phan giai Khi khao sat gan, nha lam sang nen tan dung
tuyet vi vi au do array thang 7,5-10 MHz a toi a kha nang hien th tc th cua sieu am bang
pho bien tren cac may sieu am hien ai, mac du cach khao sat gan luc ngh va luc hoat ong chu
cac may mi vi au do c hoc 13-20 MHz bay gi ong va thu ong qua thu thuat gap va duoi hay
a san co tren th trng. Trng quan sat cua au bang cach s di s theo doi tc th lien tuc.
do 7,5 hay 10 MHz luon b gii han be rong 3 en
4 cm va se giam khi i tang tan so. Hau het cac HNH ANH SIEU AM BNH THNG
may sieu am eu co the phan man hnh ra thanh
hai hnh anh ke nhau. Tuy nhien, luon co mot nguy Tat ca cac gan bnh thng co phan am va bieu
c chong hnh gia hai hnh, do o so o cua ton hien la mot cau truc phan am co hnh si nho
ac biet (Hnh 27-1)3 tren hnh cat doc. Khi sieu
am gan tan so 13 en 20 MHz, dang hnh si nho
tr nen ro net hn (Hnh 27-2). Cac ng phan am
KY THUAT KHAO SAT
ro net c chng minh la tng ng vi ranh gii
Dung au do array thang
gia bo si collagen va chat noi gan.4 Mac du de
Dung tan so cao nhat co c quan sat khi c bao quanh bi c phan am kem,
Dung mieng em cho cac cau truc nam qua nong nhng gan kem phan biet hn khi c bao quanh
Tranh tao cac anh gia co phan am kem gia do at bi m co phan am. Mot bc quan trong e xac
au do khong ung goc o. nh c gan la chung di ong khi quan sat bang
Luon phoi hp hnh cat doc va ngang sieu am hien th tc th tren hnh cat doc. Tren lat
Kiem tra gan oi ben e tham khao. cat ngang, cac bo si phan chieu se cho mot dang
Thc hien khao sat ong khi gap va duoi phan am lom om nho (Hnh 27-2; Hnh 27-3).
Cung co the dung doppler mau (kieu nang lng).
Hnh cat ngang se cung cap so o chnh xac nhat
cua o day cua gan.3
Gan c 865
Hnh 27-1. Gan Achille bnh thng. A. Hnh cat doc thc hien bi au do 5MHz cho thay cau truc
dang si, co phan am cua gan (mui ten), F, tam giac m Kager; FHL, gan gap ngon cai dai; S, mieng
em; T, x. chay. B. Hnh cat doc thc hien bi au do 10 MHz cho thay cau truc phan am dang si cua
gan ro net hn (mui ten). Chu y trng quan sat giam lai khi so vi A. C. Hnh cat doc c thc hien vi
trng quan sat rong hn (Siescape, Siemens) cho thay toan bo chieu dai cua gan Achilles (au mui ten)
t nguyen uy cho en cho en cho bam tan vao xng got. C , xng got; F, tam giac m Kager; FHL,
gan gap ngon cai dai; S, tan cung cua c dep; T, xng chay.
Hnh 27-2. Ban tay bnh thng, vung mo cai. A. Hnh sieu am cat doc vi tan so 20 MHz
cho thay gan c gap ngon cai dai co phan am (mui ten). B. Hnh cat ngang cho thay thiet dien cat
ngang hnh oval co phan am cua gan (mui ten).
Hnh 27-3. Cac gan Achille bnh thng. Hnh cat ngang gan Achille ben trai va phai co
phan am bnh thng (mui ten) vi benh nhan trong t the nam sap cho thay hng chech cua
mat phang gan.
Gan c 867
Hnh 27-4. Gan gap bnh thng cua ngon th 3 long ban tay c khao sat vi
au do 15MHz. A. Hnh sieu am cat doc cho thay gan gap nong, S, va sau, D, co phan am (mui ten
ngan) vi cau truc si noi bat. Mui ten dai ch bao hoat dch. B. Hnh cat ngang cho thay thiet dien
cat ngang co phan am cua gan nong, S, va sau, D. Mui ten ch bao hoat dch.
Cac xng vng bieu hien la cau truc phan am

manh co bong lng am. Bao hoat dch c thay
ro tan so 7,5 MHz. Tuy nhien, tan so 15
MHz, chung bieu hien la mot ng vien gan
mong co phan am kem (Hnh 27-4). Tui hoat dch
ln nhat (sau di banh che, sau xng got) co the
quan sat thay tren sieu am di dang cau truc ay
dch, mong, ch day khoang vai mm (Hnh 27-5).5
Anh gia ang chu y nhat trong sieu am gan la
tao phan am kem gia do chum tia sieu am chech.
e hien th tot nhat cau truc si co phan am cua
gan, chum tia sieu am phai vuong goc tuyet oi
vi truc cua gan. Chum tia du nam chech t nhat
cung gay phan tan chum tia tao ra phan am kem
gia tao.6 Nhng mo ta sai lam trc ay ve gan
bnh thng co phan am kem, ac biet gan chop
xoay, la do anh gia nay. Anh gia nay luon xay ra Hnh 27-5. Tui hoat dch di banh che bnh
vi au do phased array cong, c hoc, hay array thng. Hnh cat doc cua goi cho thay, tui hoat dch di
cong, la cac au do ma ch co phan gia cua hnh xng banh che (mui ten) pha sau phan di gan banh che.
la khong b anh gia va hien th c phan am bnh T, xng chay. P, gan banh che.
thng cua gan (Hnh 27-6). Khi dung mot au do

array thang, anh gia ch xay ra khi gan khong song
song vi be mat au do. Khi b anh gia do ng i
cua gan uon cong, thay oi v tr cua au do hoac
lam mat cho cong cua gan bang cach co c se lam
anh gia bien mat (Hnh 27-7). Khi s dung mieng
em, ieu quan trong la can phai kiem tra ky thuat
xem be mat au do co song song vi truc gan
khong. Hnh cat ngang cung b anh hng tng t
bi anh gia co phan am kem gia (Hnh 27-8).
Hnh 27-6. Phan am kem gia cua gan banh che bnh
thng gay ra bi au do array cong. Tren hnh cat doc
cua phan di gan banh che vi tan so 10 MHz, gan co phan am
bnh thng (mui ten) ch phan chnh gia hep cua au do ni
chum tia vuong goc vi gan. ca hai ben, s chech cua chum tia
a tao phan am kem gia cua gan (mui ten m).
Hnh 27-7. Phan am kem gia cua gan banh che bnh thng gay ra bi ng i uon
ln cua gan luc ngh. A. Hnh cat doc luc ngh cho thay gan uon ln (au mui ten) vi anh gia
tren oan gan b chech vi chum tia (mui ten), B. C bon au co lai lam thang gan (au mui ten) va
tao phan am bnh thng. T, xng chay.
Gan c 869
Hnh 27-8. Phan am kem gia cua

gan Achilles bnh thng tren au
cat ngang do gap hng au do. A.
Hnh cat ngang hi nghieng cho thay gan
phan am kem (mui ten). B. Hnh cat ngang
vuong goc tuyet oi vi truc cua gan cho
thay phan am bnh thng cua gan (mui
ten)
Vung vai tay mc o va (Hnh 27-10). Than kinh gia i

Sieu am chop xoay va phan con lai cua vai a ra pha trc cac gan gap cua ngon hai ben ngoai
c e cap chng 26 mo hoat dch ben tru. Tren hnh cat ngang, se thay
cac gan gap di ong nhieu khi nam cac ngon tay
Khuyu lai. Than kinh gia cung thay oi hnh dang ro khi
Vi khuyu gap 900, gan c ba au canh tay se de cac gan nay di chuyen sang ben. Than kinh gia co
dang nhan biet tren ca hnh cat doc va ngang. Gan phan am hi giam hn gan. Thc s, khi dung au
chung cua c gap va duoi cang tay, lan lt bam do tan so rat cao, than kinh gia, cung nh cac than
vao loi cau trong va ngoai, cung se c boc lo kinh ln ngoai bien khac se bieu hien di dang
(Hnh 27-9). Gan c hai au canh tay se thay ro nhieu ong nho, mong phan am kem, vi khoang
cho bam vao loi cu xng quay. xen ke gia chung la nguyen nhan tao ra toan bo
o phan am manh cua day than kinh (Hnh 27-
Ban tay va co tay 10,B).8,9
Trong ong co tay, cac gan gap ngon tay phan am Trong long ban tay, cap gan gap nong va sau
kem c bao boc xung quanh bi mo hoat dch ngon tay bieu hien ro. Tren hnh cat doc, vai tro
ben tru phan am kem va thay ro nhat khi gap co cua gan tng ngon tay c hien th ro tren sieu
Hnh 27-9. Khuyu bnh thng. Hnh cat

mat phang tran cua mat ngoai khuyu thc hien
bi trng quan sat rong (Siescape,Siemens)
cho thay toan bo chieu dai cua gan duoi chung
cang tay co phan am bnh thng (au mui ten)
bam tan loi cau ngoai. (H): xng canh tay;
(R): xng quay.
Hnh 27-10. Co tay bnh thng. A. Hnh cat ngang vi tan so 7,5 MHz vi co tay
hi gap cho thay thiet dien cat ngang co phan am bnh thng cua gan gap nong va sau
cua ngon tay (mui ten), no nam trong bao hoat dch tru phan am kem. Mui ten cong, than
kinh gia. B. Hnh cat ngang vi tan so 20 MHz bieu th than kinh gia (mui ten), co
phan am kem hn gan gap nam ben di.
Gan c 871
am hien th tc th khi gap duoi ngon o. Tren hnh gan banh che hi lom pha trc khi goi duoi va
cat ngang, cap gan gap nong va sau hien th la cac t the ngh ngi, nen lam sieu am luc gap goi
cau truc tron co phan am, nam ke cac c giun phan hay co c bon au, gan duoi se thang va khong tao
am kem tng ng (Hnh 27-11). anh gia phan am kem (Hnh 27-7).
Trong ngon tay, gan gap i theo mat lom cua Gan c bon au ui bao gom bon gan (gan c
xng ot ngon,va do o b anh hng bi anh gia thang ui, rong ngoai, rong trong, va rong gia),
phan am kem doc theo hau het hanh trnh cua ma thng kho phan biet rieng le tng gan tren
chung, ngoai tr oan nao vuong goc tuyet oi vi sieu am. Gan bon au nam di m di da va
chum tia sieu am (Hnh 27-12).8,9 nam pha trc lp m em va tui hoat dch xep
tren xng banh che (Hnh 27-13). Tren hnh cat
Goi ngang, gan bon au co hnh bau duc.
Sieu am la mot ky thuat tuyet vi e quan sat cac Gan banh che keo dai t xng banh che en
gan duoi cua goi.10,11 Do ca gan bon au ui va loi cu xng chay (Hnh 27-14), tren mot oan dai
t 5 en 6 cm. Tren mat cat ngang, gan banh che
co mat loi pha trc va phang pha sau. Tai phan
gia, gan co be day khoang 4 en 5 mm va rong 20
en 25 mm. Khong thay c mo hoat dch sau va
trc banh che di da. Mo hoat dch sau banh che
nam sau, co the hien th di dang mot cau truc
phan am trong, dep, day 2 en 3 mm (Hnh 27-5).
Sieu am a c dung trong viec anh gia
cac day chang ben, nhng khong phai luon luon
de phan biet cac day chang bnh thng vi bao
khp va mo di da xung quanh.12 Mot vai bao cao
cho thay ket qua kha quan trong viec anh gia cac
day chang cheo.13,14 Tuy nhien, viec dung sieu am
Hnh 27-11. Long ban tay bnh thng. Hnh sieu am khao sat cac cau truc nay se b han che do thc s
cat ngang cho thay cac gan gap nong va sau, tron co phan khong the thay chung, neu khong th cung b chech
am bnh thng cua ngon III, IV (mui ten) nam ke ben cac
chum tia tao hnh anh phan am kem gia. Do o kho
c giun phan am giam (mui ten cong). Sieu am Doppler kieu
nang lng cho thay co dong mau trong cac M gan tay anh gia chung ngoai tr trng hp t gan hoan
chung. M, xng ban tay.
Hnh 27-12. Ngon tay bnh thng. Hnh cat doc vi trng quan sat rong (Siescape, Siemens) cho
thay cac gan gap nong va sau bnh thng (au mui ten) i doc theo xng ngon tay. Chu y cac gan co phan
am bnh thng ch nhng oan song song vi au do array thang; gan se phan am kem gia nhng oan
nam chech vi chum tia.M , xng ban tay; P1, ot 1; P2, ot 2; P3, ot 3.
toan. a thanh luat, day chang cheo c khao sat am kem, dep oi khi quan sat c goc tao bi
tot hn bang MRI. gan va xng got. Cac si cua gan tai cho bam vao
xng co mot oan ngan i chech gay phan am
Ban chan va co chan kem gia (Hnh 27-15). Khong nen chan oan lam
Gan Achilles c tao nen bi s ket hp gia can vi tui hoat dch gan got di da, ma bnh thng
c dep va c bung chan. No bam vao mat sau cua khong thay c. Gan ay, mot nghien cu sieu
xng got. Neu khong b anh gia, gan Achilles co am c thc hien vi tan so 10 en 15 MHz cho
phan am va bieu hien di dang mot cau truc si thay s hien th cua hai gan co o phan am khac
ac trng tren hnh cat doc (xem Hnh 27-1).15 Tan nhau, ac trng cho cac phan xuat phat t c dep
cung cua c dep phan am kem de dang nhan ra va c bung chan.16
pha trc au gan. Tam giac m Kager, nam pha Tren hnh sieu am cat ngang, mat cat ngang
trc na di cua gan, luon co phan am, nhng co cua gan ve ai the co hnh elip va hi thon nhon
the co mot so iem khac nhau ve o phan am ben trong. Mat phang cua gan ro net khi no chech
tng ca nhan. Nam pha trc hn la c gap ngon ra trc va vao trong (xem Hnh 27-3). Do ac tnh
cai dai phan am kem va mat sau co phan am cua nay ma co mot nguy c anh gia qua mc bnh
c chay. Bao hoat dch di gan got co phan thng o day cua gan hnh tuyet oi cat doc
gia , do o nen lay so o tren hnh cat ngang.
Tren cho bam 2 en 3 cm, gan Achilles day 5 en
7 mm va rong 12 en 15 mm.15 Ngi ta a ghi
nhan c s tng quan gia o day cua gan va
chieu cao cua chu the.17 Mot nghien cu khac cho
thay gan Achilles cua van ong vien rong hn
nhng chu the oi chng, va cung cho rang s
luyen tap lau dai se lam gan to ra.
co chan, sieu am de khao sat gan c mac
dai va ngan ben ngoai va gan c chay sau ben
trong. Gan c gap cac ngon dai va ngon cai dai
cung c thay pha sau mat ca trong, trong khi
gan c chay trc, duoi ngon cai dai, va duoi cac
ngon dai c thay mat trc co chan. Khao sat
ong khi lam thu thuat ac biet gap va duoi co
chan va ban chan giup xac nh tng gan rieng
biet. Cac gan co chan c boc trong bao hoat
Hnh 27-13. Gan bon au bnh thng. Hnh cat doc cho
thay gan co phan am (mui ten) c boc xung quanh bi m . dch. Trong mot nghien cu mi ay, ngi ta thay
F, xng ui, P, xng banh che. co mot lng dch nho trong bao gan chay sau va
Hnh 27-14. Gan banh che bnh thng. A. Hnh cat doc c thc hien vi au do 10 MHz cho
thay cau truc phan am dang si cua gan (mui ten). Chu y cac si trc banh che (mui ten m). P, xng
banh che. B hnh cat doc vi trng quan sat rong (Siescape, Siemens) cho thay toan bo gan (au mui
ten) trai dai t xng banh che en loi cu xng chay, gan day khoang 4 mm. P, xng banh che, T,
xng chay.
Gan c 873
bao gan mac chung, lan lt la 71% va 12% co Khi khong co nhng yeu to nguy c tren, mau mo
chan nhng ngi tnh nguyen khong co trieu sinh thiet lay vung gan cho rach thng cho thay
chng.18 co nhng bien oi thoai hoa, oi khi c mo ta la
ban chan, ky thuat khao sat va hnh anh sieu benh ly gan.
am bnh thng cua gan gap va chuoi cac ngon Rach hoan toan. Cac ton thng rach hoan
chan khong khac lam vi cua gan ngon tay.9 toan gan ay thng c chan oan chnh xac
bang lam sang. Tuy nhien, neu kham lam sang
BENH HOC muon se kho xac nh v cac bien oi do viem.
Sieu am co the cho thay s mat lien tuc toan bo be
Cac bat thng cua gan hau het la do chan thng day cua gan. Khoang trong gia hai au gan rach
(rach) hay viem (viem gan). lap ay dch xuat huyet phan am kem (hoac cuc
mau ong) hay mo hat, tuy thuoc vao thi gian cua
Rach ton thng (Hnh 27-16). Khoang trong nay co o
Ton thng rach luon xay ra tren cac gan ma de dai rat thay oi, va khi hai au gan xa nhau nhieu
ton thng do nhng yeu to nh: lao hoa, co hien se hoan toan khong thay c gan. S khiem dien
tng voi hoa, ien tr corticoid tai cho hoac toan nay co the xay ra trong rach hoan toan chop xoay
than, va cac benh he thong co san (viem khp va gan gap cac ngon tay.23 Vi trng hp ngoai le
thap, lupus ban o, tieu ng va thong phong).19-22 cua rach gan Achilles ma mot khoi mau tu co the
hnh thanh quanh toan bo gan, cho rach luon kem
theo o xuat huyet nho. Trong trng hp bong rt
gan khoi xng, mot manh xng co the thay nh
CAC TRIEU CHNG SIEU AM CUA RACH mot o phan am sang co bong lng am (Hnh 27-17)
GAN Rach khong hoan toan. Rach khong hoan
toan rat kho chan oan tren lam sang va kho phan
Mat lien tuc cac si gan (tng phan hoac hoan toan). biet vi viem gan khu tru. Chan oan sieu am
Mau tu cac c, thng la nho. chnh xac se rat quan trong v chan oan va ieu tr
Manh xng trong trng hp rt manh xng. sm mot ton thng rach gan ban phan se ngan
Khiem dien do gan tut lai trong trng hp rach chan c dien tien rach gan hoan toan. o nhay
hoan toan.
94% vi chan oan bang sieu am rach ban phan
gan Achilles a c bao cao.24 Cac nghien cu
Hnh 27-15. Phan am kem gia cua gan Achilles bnh thng tai cho bam vao xng
got. A. Hnh cat doc vi au do Array thang song song vi gan (au mui ten) cho thay oan xa co phan
am kem ro ret cua gan (mui ten) co ng i chech vi chum tia. B. at au do song song vi phan xa
cua gan a loai bo c anh gia (mui ten), trong khi phan con lai cua gan (au mui ten) bay gi lai co
phan am kem gia. C, x. got.
Hnh 27-16. t hoan toan gan Achilles. Hnh

cat doc cho thay oan tren sng ne , rut lai (mui ten).
Hnh 27-17. t hoan toan gan chay sau tai cho bam vao xng thuyen. A. Hnh chup
MRI cua ban chan (nham so sanh vi hnh sieu am) cho thay gan b t (mui ten). Mui ten m ch gan
bnh thng. N, xng thuyen. B, Hnh sieu am mat phang tran cho thay o mau tu phan am kem va s
mat lien tuc cua gan (mui ten). Mui ten m ch gan bnh thng. Mui ten cong ch manh xng b rt. C,
X.quang xac nh manh xng b rt tai cho bam cua gan (mui ten) vao xng thuyen.
Gan c 875
Hnh 27-18. Rach ban phan gan Achilles. Hnh cat

doc cua gan cho thay s mat lien tuc khu tru cua th si (mui
ten) mat sau cua gan.
TRIEU CHNG SIEU AM CUA VIEM GAN
Day gan
Phan am giam
B m khong ro
Tang tuan hoan tren hnh Doppler mau
Voi hoa trong viem gan man
khac cung ghi nhan tnh u viet cua MRI so vi Hnh 27-19. Rt ban phan cua phan tren gan banh
sieu am trong chan oan rach khong hoan toan gan che. A. Hnh cat doc gia cho thay mau tu va s mat lien tuc
Achilles .25,26 cua gan (mui ten) tai cho bam tren cua gan. P, xng banh
Tren sieu am, cac ton thng rach ban phan che. B. Hnh cat ngang cho thay khoi mau tu ng gia co
phan am kem, tron, gii han ro (mui ten), au mui ten, b gan.
mi ay se bieu hien la khuyet co phan am kem
khu tru trong gan hoac tai cho bam cua no (Hnh
27-18).5,24,27 anh gia ba chieu ton thng rach ban cho phep theo doi cac ton thng viem va ghi nhan
phan can phoi hp cac hnh cat doc va ngang. ap ng ieu tr.28
Khi gan banh che rt mot phan khoi nh
xng banh che, hnh cat doc co the thay s mat Viem gan. Viem gan thng gap nhat cac
lien tuc cua cac si gan trong khi cac hnh cat hoat ong nghe nghiep va the thao. Tren quan sat
ngang pha di nh banh che cho thay cho benh hoc, cac bien oi thoai hoa thng kem theo
khuyet tron ng gia cua gan (Hnh 27-19) s hien dien cua cac ken nho. Hien tng tang
tuan hoan va phu lam tang the tch gan. Co the
Viem xay ra voi hoa trong viem gan man. Viem gan co
Hien tng phu kem theo vi viem gan va/ hoac the anh hng en toan bo hoac ch mot phan cua
cau truc xung quanh gay day gan va giam phan am gan. gan banh che, viem gan khu tru luon xay ra
cua gan b viem. Hien nay, s tang tuan hoan nay cho bam pha tren, nhng viem khu tru cho bam
kem theo vi viem co the quan sat c bang chan ben di cung co the xay ra khi chuyen loi cu
oan hnh anh Doppler mau (kieu nang lng). xng chay.
Khi nh lng khach quan s tang tuan hoan bang Trong viem gan cap, gan day len va b cua
sieu am Doppler mau tr nen thng quy, no se no se thng khong ro rang. Cung co giam phan
am lan toa (Hnh 27-20).14,15 Do quet hnh khong khi co mot anh gia uoi sao choi (Hnh 27-21,A).
ung cung co the gay phan am kem gia cua gan, v Tuy nhien, kch thc va hnh dang cua cac not voi
the ky thuat khao sat phai hoan hao. Viec so sanh hoa nay thay ro hn tren X quang ien the thap,
hnh sieu am vi gan oi ben bnh thng rat co ac biet khi dung may chup nhu anh (Hnh 27-
gia tr. 21,B).29
Trong viem gan man, hnh dang cua gan co Sieu am Doppler mau (kieu nang lng) co
the b bien dang vi hnh dang go ghe. Sieu am tan the cho thay s tang tuan hoan khu tru hoac lan toa
so cao a chng minh tnh chnh xac trong viec (Hnh 27-22). S xuat hien dong mau trong mot
phat hien cac not voi hoa nho trong gan, bieu hien vung khu tru co phan am giam ang ke se giup xac
la cac o sang co hoac khong co bong lng am, oi nh chan oan viem gan khu tru va loai bo ton
thng rach ban phan cap v dong mau khong hien
dien trong cho khuyet a lap ay mau do rach
(Hnh 27-23). Co the dung sieu am Doppler mau
e kiem soat ap ng cua benh nhan vi lieu
phap khang viem. Giam kch thc gan va phan
am tr lai mc bnh thng va tuan hoan rat t cho
ta biet a khoi benh.
Viem mang gan. Trong viem mang gan, hien
tng viem ch gii han mang gan, la lp mo lien
ket bao phu xung quanh gan. Tnh trang nay
thng gap gan Achilles. Tren sieu am, viem
mang gan bieu hien bi day mang gan co phan am
giam, vi phan gan con lai khong b anh hng
nhieu. Sieu am Doppler mau (kieu nang lng)
thng cho thay hien tng tang tuan hoan (Hnh
27-24).
Viem bao gan. Viem bao gan c nh
Hnh 27-20. Viem gan banh che cap. Hnh cat doc cho ngha la tnh trang viem cua bao gan. Bat ky gan
thay s day len va giam phan am cua hai phan ba tren cua gan nao c bao quanh bi bao gan, ac biet gan co
(mui ten). (F) loi cau xng ui. P, xng banh che. tay, co chan eu co the b anh hng. Chan thng,
Hnh 27-21. Viem gan banh che voi hoa man tnh. A. Hnh cat doc cho bam ben di cua gan cho
thay gan co phan am kem, day len ang ke (mui ten dai) vi b vien m va nhng not nho voi hoa phan
am manh (mui ten ngan), moi not co anh gia uoi sao choi (au mui ten). B Hnh X. quang nghieng ien
the thap chup bang may chup nhu anh cho thay gan banh che sng len, va co nhng not voi hoa nho (mui
ten). T, xng chay. P, xng banh che.
Gan c 877
Hnh 27-22. Viem gan Achilles cap. Hnh sieu am Doppler mau kieu nang lng cat doc cho
thay tang tuan hoan ang ke mat sau cua gan. Chu y o phan am cua gan giam ang ke. (c
phep cua Dr. D.H. Touche.)
Hnh 27-23. Viem gan banh che cap. Hnh cat doc gia Doppler mau kieu nang lng cho
thay tang khu tru tuan hoan gan vung giam phan am (mui ten) gan vi nh banh che. Mui ten
ngan ch ra gan banh che. P, xng banh che. (c phep cua Dr. D.H. Touche.)
Hnh 27-24. Viem mang gan. Hnh cat doc Doppler kieu nang lng cua gan Achilles cho thay
tang tuan hoan mang gan sng ne co phan am kem pha sau. (c phep cua Dr. D.H. Touche.)
Hnh 27-25. Viem bao gan gap ngon tay. Hnh cat doc
cua mat long khp ban tay cho thay bao gan cang len do mot t
dch (au mui ten), gan gap bnh thng (mui ten). M, xng
ban . P1, ot 1.
Hnh 27-26. Viem bao gan De Quervain. Hnh cat
ngang co tay cho thay bao hoat dch phan am kem, day len
bao gom ca vi chan thng lap i lap lai, va nhiem (mui ten) bao quanh gan dang ngon cai dai va gan duoi ngan
trung la nguyen nhan thng gap nhat cua viem cai ngan.
bao gan cap. Cac trng hp viem bao gan do mot
ngoai vat con sot trong mot bao gan ban tay cung
a c bao cao. Tren sieu am, chan oan viem cua gan trong ng i chat hep. Trong viem bao
bao gan cap khi co dch trong bao gan, du la mot gan De Quervain, gan dang ngon cai dai va duoi
lng nho (Hnh 27-25).31,32 Trong viem bao gan ngon cai ngan b siet chat bi bao day trong rong
mu, co the thay nhng phan am cua cac manh vun roc ngay tren mong tram quay. Sieu am co the cho
ben trong, tnh trang nghiem trong nay co the anh thay day bao gan co phan am kem (Hnh 27-26).9,34
hng nhanh chong en gan.33 Sieu am Doppler mau cho thay tang tuan hoan
Viem gan man ac trng bi bao hoat dch day mo b viem. Sieu am con co the c dung e
len co phan am kem, thng co t hoac khong co chch chat can quang va bao gan nh: chup gan can
dch. Day bao hoat dch co the can tr van ong quang, mot ky thuat ch e tao bong cua vo bao
Gan c 879
Hnh 27-27. Viem bao gan do thap gan duoi cua

mot ngon mat lng ban tay. Hnh cat ngang cho thay Hnh 27-28. Viem bao hoat dch. Hnh cat ngang mat
mang viem phan am kem (mui ten) bao quanh gan (mui ten sau khuyn cho thay bao hoat dch mom khuyu cha ay dch,
m). M, xng ban. thanh day. Hnh Doppler mau kieu nang lng cho thay tang
tuan hoan bao hoat dch. O, mom khuyu.
ch khong the bieu lo o day. Sieu am cung co the hieu thng gap nhng ngi trai tham41. giai
c dung e hng dan chch steroid vao bao oan man tnh, mot hnh anh sieu am hon hp vi
hoat dch gan chay sau benh nhan benh viem cac manh vun co phan am ben trong la do cac mo
khp man tnh.36 hat, si ket tua, va oi khi co voi hoa. Sieu am
Benh viem khp dang thap rat co ai lc vi Doppler mau thng cho thay co s tang tuan hoan
mo hoat dch, va bao gom ca bao gan au chi. trong vach day len cua tui hoat dch (Hnh 27-28)
Sieu am a c chng minh rat hieu qua trong Benh sun xng ngoai khp. Benh Osgood-
chan oan viem bao gan dang thap ban tay.37 Schaltter va Sinding-Larson-Johansson eu la benh
Bao gan b anh hng bi mang mau (pannus) co sun xng ngoai khp cua goi xay ra trung tam
phan am kem rat ro (Hnh 27-27), va oi khi cung cot hoa de b tac ong bi lc cang qua mc. Ca
co dch trong bao gan. Sieu am Doppler mau cho hai benh ly nay eu xay ra tuoi thieu nien, ien
thay co tang tuan hoan ang ke mang mau. Cac hnh nhng be trai co hoat ong the thao. Mac du
dau hieu sieu am cua gan b viem bao gom day va chan oan chu yeu da tren benh s lam sang,
khong ong nhat cua gan co b loi lom.38 giai nhng hnh anh X quang van thng c dung e
oan sau, sieu am cho thay gan mong i ro ret xac nh chan oan. Gan ay, sieu am o phan
hoac rach ban phan hoac toan phan.39 giai cao a c dung e anh gia cac benh ly
Viem tui hoat dch. Viem tui hoat dch nay.
thng xay ra nhat tui hoat dch di c delta, Benh Osgood Schalter la benh sun xng cua
mom khuyu, chom quay-canh tay, banh che, va loi cu xng chay. Trong nghien cu tren 70 trng
got. Chan thng, va quan trong hn, la vi chan hp, sieu am a phat hien ra phu ne cua lp sun
thng lap i lap lai c tin la ong mot vai tro phan am trong trong 100% cac trng hp, v vun
quan trong trong viem tui hoat dch, cho du khong trung tam cot hoa co phan am cua loi cu trc
tm thay yeu to khi phat trong nhieu trng hp. xng chay trong 75% trng hp, day lan toa gan
That ly thu khi ngi ta chng minh c rang co banh che trong 22% cac trng hp, va viem tui
s tch tu dch thoang qua trong tui hoat dch di hoat dch sau di banh che trong 17% cac trng
mom cung tren sieu am vung vai len en 16 en hp.
20 gi sau tap bong nem.40 Trong giai oan sm Benh Sinding- Larsen Johansson la benh ly
cap tnh cua viem tui hoat dch, khi tui hoat dch sun xng cua trung tam cot hoa phu cc di
cha ay dch, sieu am cho thay mot hnh anh tui xng banh che. benh ly hiem gap nay, sieu am
dch ay dch co phan am gan nh trong, vi b co the cho thay trung tam cot hoa phan am, v vun
khong ro. Viem tui hoat dch trc banh che la dau (fragmented) va lp sun va mo mem xung quanh
Hnh 27-30. Hnh thai sau mo. Hnh cat doc gan
Achilles cho thay gan day len ang ke (au mui ten) cha
Hnh 27-29. Hnh thai sau mo. Hnh cat doc gan banh mot dai phan am co bong lng, la vat lieu phau thuat tang
che c thc hien 15 thang sau mo viem gan cho thay mot cng tong hp (Polydioxanone sulfate) (mui ten). Chu y o
gan phan am kem, khong ong nhat, day lan toa (mui ten) phan am sang la cac moi ch (mui ten cong).
vi b khong ro va cac not voi hoa nho (mui ten m). (P)
xng banh che
phan am kem, phu ne, ke ca nguyen uy cua gan gia nh, sieu am co the thay nhieu u vang phan
banh che. am kem gan Achilles trong 95% benh nhan va co
the phat hien cac u vang khu tru sm trong gan
Cac hnh thai sau mo cha ph ai. Trong nhom 30 ngi trng thanh
Sau khi ieu tr phau thuat, gan tr nen rong ra va vi chng tang cholesterol mau gia nh, o day
khong ong nhat vi b khong eu, m tren sieu trung bnh cua gan Achilles la 11,1 mm so vi 4,5
am (Hnh 27-29).5,45 Hnh dang sau mo nay co the mm ngi bnh thng va 4,9 mm nhom tang
ton tai nhieu thang hoac nhieu nam, do o sieu am cholesterol mau khong co tnh gia nh. Ngi ta
khong the phan biet chnh xac ton thng rach lai cung chng minh rang sieu am co the phat hien ra
vi viem gan do bien oi sau mo. oi khi sieu am tnh trang tham nhiem co phan am kem cua gan
co the phat hien ra cac o phan am sang do con sot Achilles trong 38 benh nhi b chng tang
lai ch tong hp hay do voi hoa (Hnh 27-30). Sieu cholesterol mau gia nh. Ngc lai, mot nghien
am Doppler co the cho thay s tang tuan hoan con cu khac khong cho thay co bat thng ang ke
sot lai trong gan sau mo. nao trong chng tang cholesterol mau (khong co
tnh gia nh) th phat. Sieu am con co the c
U va gia u dung e theo doi hieu qua ieu tr tren cau truc
U lanh cua gan hay bao gan bao gom u ai bao phan am va be day cua gan Achilles.
(gaint cell tumor) va u sun xng (osteochon- Not thap trong gan (intratendinous) xuat hien
droma. U ai bao mang gan c cho la mot dang tren sieu am di dang cac not co phan am kem.
gii han cua viem mo hoat dch dang not nhung Ngc lai, cac tophi trong gan co dang cac o phan
mao co sac to . No thng xay ra mat long cua am manh co bong lng am, no cho phep phan biet
ngon tay va luon thay ngi phu n tre va trung vi cac not thap trong gan.
nien. S tai phat tai cho co the xay ra neu lay Trong benh ly thoai hoa dang bot do tham
khong tron khoi u khi mo. Tren sieu am, u ai bao tach (dialysis-related amyloidosis), hoat mac khp
co dang khoi phan am kem, oi khi co phan thuy.9 va bao khp va gan (nh gan tren gai) co the day
U ac hiem gap, sarcoma mo hoat dch co the len, vi s day len do qua trnh tham tach.
xuat phat t bao gan. Chung hien dien nh mot Nang hoat dch thng gap nhat ban tay
khoi co thuy phan am kem oi khi co nhng not nhng co the xay ra bat ky khp hoac bao gan
voi hoa. nao. Sieu am cho thay mot tui dch hnh oval nam
nhng benh nhan b tang cholesterol mau ke ben o khp hoac gan (Hnh 27-31). oi khi,
Gan c 881
Hnh 27-31. Nang hoat dch tren mat long cua ot

th nhat ngon tay th hai. Hnh cat doc cho thay mot
cau truc dang nang 0,8 cm, gii han ro (mui ten) pha trc
gan gap ngon tay (au mui ten). Chu y s tang am pha xa.
M, xng ban. P, ot th 1. Hnh 27-32. Nang vung khoeo. Hnh cat doc cho thay
mot khoi dang nang hnh giot nc mat (mui ten) trong mo
mem pha sau khp goi vi phan nho hn (mui ten cong)
pha trc c bung chan trong. Chu y phan am ben trong do
hoat mac ph ai. F, xng ui. T, xng chay.
nang man tnh hay nang cha dch nhn co phan co the gap kho khan khi chan oan bang sieu am
am ben trong, lam cho nang hien th giong nh mot do dch ro a c hap thu va ch con lai mot vung
u ac phan am kem. phan am kem kho xac nh.
Nang khac thng xay ra vung gan khp la
nang vung khoeo. Nang vung khoeo gay ra bi s SIEU AM SO VI CAC PHNG PHAP
cang phong bat thng cua tui hoat dch gan c CHAN OAN HNH ANH KHAC
ban mang bung chau, no thng thong thng vi
khp goi thong qua mot lo rach mat sau trong Trong nhieu thap nien qua, X quang ien the thap
cua bao khp. Chung thng c thay i kem vi va chup X quang kho la ky thuat hnh anh duy
mot so tnh trang benh ly gay tang ap lc trong nhat cho gan. Mac du chung co the tao bong gan,
khp nh san xuat qua mc hoat dch, x hoa bao ac biet khi gan c m bao xung quanh, nhng
khp, hay ph ai hoat dch; trong so cac benh ly chung khong the hien th cau truc cua gan. Tuy
nay, viem khp dang thap la thng gap nhat. nhien chung van la cac phng phap tot nhat ghi
Nang vung khoeo bieu hien tren lam sang di nhan cac not voi hoa ro rang trong gan hay tui hoat
dang mot khoi u khoeo co hoac khong co trieu dch.
chng. Nhng nang ln lan vao c hay v ra gay Chup gan c thc hien bang cach bm chat
au, phu ne chan giong nh viem tac tnh mach. can quang vao bao gan, ky thuat hnh anh b lang
Mot nang vung khoeo ien hnh tren sieu quen nay cho thay hnh anh toan bo chi tiet cua
am la mot tui ay dch. oi khi hnh cat doc cho thanh trong bao gan nhng khong the anh gia o
thay mot vung phan am trong th phat pha trc day cua thanh nh sieu am.
gan c bung chan. Hnh cat ngang xac nh de V CT b gii han cac lat cat ngang cua chi
dang ca hai vung la cac phan cua cung mot nang khi chup thng qui va khong the co o phan giai
bao xung quanh gan c (Hnh 27-32). Cac phan am can quang ay u, nen no hiem khi c dung
ben trong la cac dai si hay manh vun va day hoat trong khao sat gan.
mac co the thay c trong cac nang b viem, MRI a noi len nh mot phng phap chnh
nhiem. benh nhan viem khp dang thap, mot xac e khao sat bang hnh anh cac mo mem va la
nang vung khoeo co the cha ay mang mau, de oi thu canh tranh trc tiep vi sieu am tan so cao
lam vi mot khoi ac. U sun xng cung co the trong lnh vc chan oan hnh anh gan. Tuy nhien
phat trien trong nang vung khoeo, tao ra cac manh hien nay, sieu am tan so cao la ky thuat hnh anh
l lng co phan am manh, tao bong lng am khi b cat ngang, hien th tc th duy nhat. Hnh anh sieu
voi hoa. Trong mot nang mi v, sieu am co the am co the nhanh chong at c bat ky hng
lan xuong bung chan. Tuy nhien, neu khao sat tre, nao va au do tan so rat cao hien nay co the cho
s phan giai khong gian va tng phan tuyet vi. 1988:31:441-446.

20. Ismail AM, Balakrislman R. Rajakumar MK. Rupture of patellar
Them vao o, chi ph sieu am thap va trang thiet ligament after steroid infiltration. Report of a case. J Bone Joint
b c pho bien rong khap. Tuy nhien, do kch c Surg 1969:51B:503-5()5.
21. Kricun R Kricun ME. Arangio GA et al. Patellar tendon
cau truc khao sat nho va kha nang tao anh gia do
rupture with underlying systemic disease. AJR 1980:135:803-807.
ky thuat, sieu am gan van phu thuoc ngi lam va 22. Morgan J. McGarty DJ. Tendon ruptures in patients with systemic
oi hoi kinh nghiem e at c ket qua chnh xac. lupus erythematosus treated with corlicosteroids. Arthritis Rheum
1974;17:1033-1036.
23. Souissi M, Giwerc M, Ebelin M et al: Exploration echographique
THAM KHAO des tendons flechisseurs des doigts de la main. Presse Med 1989;
Giai phau 18:463-466.
1. Mc Master PE. Tendon and muscle ruptures. Clinical 24. Kalebo P, Allenmark C, Peterson U et al. Diagnostic value of
and experimental studies on the causes and location of ultrasonography in partial ruptures of the Achilles tendon. Am
subcutaneous ruptures. J Bone Joint Surg 1933;15:705-722. J Sports Med 1992;20:378-381.
25. Weinstabi R. MR and ultrasound study of Achilles tendon injury
Ky thuat khao sat (in German). Unfallchirurgie 1992;18:213-217.
2. Fornage BD. Touche DH, Rifkin MD. Small parts real-time 26. Neuhold A, Stiskal M, Kainberger F et al. Degenerative Achilles
sonography: a new "water-path; J Ultrasound Med 1984;3:355- tendon disease: assessment by magnetic resonance and ultra-
357. sonography. Eur J Radiol 1992;14:213-220.
3. Fornage BD. Ultrasonography of Muscles and Tendons 27. Ueekam RN, Salsberg BB, Bogoch E et al. Sonographic
Examination Technique and Atlas of Normal Anatomy of the diagnosis of partial Achilles tendon rupture and healing.J
Extremities. New York: Springer-Verlag; 1988. Ultrasound Med 1986;5:115-116.
Hnh anh sieu am bnh thng 28. Newman JS, Laing TJ, McCarthy CJ et al. Power
4. Martinoli C, Derchi LE, Pastorino C et al. Analysis of Dopplersonography of synovitis: assessment of therapeutic
echotexture of tendons with US. Radiology 1993;186:839-843.5 response -preliminary observations. Radiology 1996;198:582-584.
Fornage BD, 29. Fornage B, Touche D, Deshayes JU et al. Diagnostic des calci-
5. Rifkin MD. Ultrasound examination of tendons. Radiol Clin fications du tendon rotulien. Comparaison echoradiographique. J
North Am 1988;26:87-107. Radiol 1984:65:355-359.
6. Fornage BD. The hypoechoic normal tendon: a pitfall. J 30. Howden MD. Foreign bodies within finger tendon sheaths
Ultrasound Med 1987:6:19-22. demonstrated by ultrasound: t wo cases. Clin Radiol 1994;
7. Silvestri E, Martinoli C, Derchi UF et al. Echotexture of 49:419-420.
peripheral nerves: correlation between US and histologic findings 31. Middleton WD, Reinus WR, Totty WG et al. Ultrasound of the
and criteria to differentiate tendons. Radiology-1995;! 97:291- biceps tendon apparatus. Radiology 1985:157:211-215.
296. 32. Gooding GAW. Tenosynovitis of the wrist. A sonographic
8. Fornage BD. Rifkin MD. Ultrasound examination of the demonstration. J Ultrasound Med 1988:7:225-226.
hand. Radiology 1986;160:853-854. 33. Jeffrey RB Jr, Uaing FC, Schechter WP et al. Acute suppurative
9. Fornage BD Rifkin MD. Ultrasonic examination of the hand tenosynovitis of the hand: diagnosis with ultrasound. Radiology
and foot. Radiol Clin North Am 1988:26:109-129. 1987:162:741 -742.
10. Dillehay GU. Deschler T, Rogers UF et al. The ultrasonographic 34. Marini M. Boni S, Pingi A e t al. De Quervain's disease:
characterization of tendons. Invest Radiol 1984:19:338-341. diagnostic imaging. Chir Organi Mov 1994;79:219-223.
11. Fornage BD, Rifkin MD, Touche DH et al. Sonography of the 35. Fornage BD. Ultrasound of the Extremities (in French). Paris:
patellar tendon: preliminary observations. AJR 1984:143:179- Vigot:1991.
182. 36. Brophy DP. Gunnane G, Fitzgerald O et al. Technical report:
12. De Flaviis U, Nessi R, Leonardi M et al. Dynamic ultrasono- ultrasound guidance for injection of soft tissue lesions around the
graphy of capsulo-ligamentous knee joint traumas. J Clin heel in chronic inflammatory arthritis. Clin Radiol 1995;50:120-
Ultrasound 1988;16:487-492. 122.
13. Rohr F. Die sonographische Darstcllung des hinteren Kreuz- 37. Fornage BD. Soft -tissue changes in the hand in rheumatoid
bandes. Rontgenblatter 1985:38:377-379. arthritis: evaluation with ultrasound. Radiology- 1989;173:.
14. Scherer MA, Kraus M, Gerngross H et al. Importance of 38. Grassi W. Tittarelli E. Blasetti P et al. Finger tendon involvement
ultrasound in postoperative follow-up after reconstruction of in rheumatoid arthritis. Evaluation with high - frequency
theanterior cruciate ligament (in German). Unfallchirurg 1993: sonography. Arthritis Rheum 1995:38:786-794.
96:47-54. 39. Coakley FV. Samanta AK. Finlay DB. Ultrasonography of the
15. Fornage BD. Achilles tendon: ultrasound examination. Radiology tibialis posterior tendon in rheumatoid arthritis. Br J Rheumatol
1986:159:759-764. 1994:33:273-277.
16. Berlolotto M, Perrone R, Martinoli G et al. High resolution 40. Kniger-Franke M, Fischer S. Kugler A et al. Stress-related
ultrasound anatomy of normal Achilles tendon. Br J Radiol clinical and ultrasound changes in shoulder joints of handball
1995:68:986-991. players (in German). Sport rerletz Sportsclwden 1994:8:166-169.
17. Koivunen-Niemela T, Parkkola K. Anatomy of the Achilles 41. Myllymaki T. Tikkakoski T. Typpo T et al. Carpet- layers knee.
tendon (tendo calcaneus) with respect to tendon thickness An ultrasonograpluc study. Acta Radiol 1993:34:496-499.
measurements. Surg Radiol Anat 1995:17:263-268. 42. De Flayns U, Nessi R, Scaglione P el al. Ultrasonic diagnosis of
18. Nazarian LN, Rawool NM. Martin GE el al. Synovial fluid in Osgood-Schlatter and Sinding-Larsen-.lohansson diseases of
the hindfoot and ankle: detection of amount and distribution the knee. Skeletal Radiol 1989:18:193-197.
with US. Radiology-1995:197:275-278. 43. Bero-ami G Barbuti D, Pezzoli F. Ultrasonographic findings in
Osgood-Schlatter disease (in Italian). Radiol Med (Torino) 1994:
Benh hoc
88:368-372.
19. Downey DJ, Simkin PA. Mack LA et al. Tibialis posterior
44. Barbuti D, Bergami G, Testa F. Ultrasonographic aspects of
tendon rupture: a cause of rheumatoid flat foot. Arthritis Rheum
Gan c 883
Sinding-Larsen-.lohansson disease (in Italian). Pediatr Med Chir 53. Compels BM, Darlington LG. Evaluation of popliteal cysts and
1995:17:61-63. painful calves with ultrasonography: comparison with
45. Blei CU. Nirschi RP, Grant EG. Achilles tendon: ultrasonic arthrography. Ann Rheum Dis 1982:41:355-359.
diagnosis of pathologic conditions. Radiology 1986:159:765-767. 54. Bouffard A, van Holsbeck M. The knee. In: Fornage BD. ed.
46. Bude RO, Adier RS, Bassett DR et al. Heterozygous familial Musculoskeletal Ultrasound. New York: Churchill Livingstone;
hypercholesterolemia: detection o f xanthomas in the 1995.
Achilles tendon with US. Radiology1993;188:567-571. 55. Moss CD, Dislmk W. Ultrasound diagnosis of osteochondro-
47. Ebeling T, Farin P, Pyorala K. Ultrasonography in the detection matosis of the popliteal fossa. J Clin Ultrasound 1984:12:232-
of Achilles tendon xanthomata in heterozygous familial 233.
Hypercholesterolemia. Atherosclerosis 1992:97:217-228. So sanh sieu am vi cac phng phap chan oan hnh
48. Koivunen-Niemela T, Viikari .1, Niinikoski H et al. Sonography anh khac
in the detection of Achilles tendon xanthoinata in children with 56. Engel J, Luboshitz SW, Israeli A et al. Tomography in
familial hypercholesterolaemia. Acta Paediatr 1994:83: 1178 DeQuervain's disease. Hand 1981:13:142-146.
1181. 57. Gilula LA. Oloff L, Caputi R et al. Ankle tenography: a key
49. Kainbero-er F, Seidi G, Train dl 0 et al. Ultrasonography of the tounexplained symptomatology. Part II: Diagnosis of chronic
Achilles tendon in hypercholesterolemia. Acta Radiol 1993: tendon disabilities. Radiology 1984:151:581-587.
34:408-412. 58. Mourad K, King J, Guggiana P. Computed tomography and ultra-
50. Tihakos N, Morales AR, Wilson CH Jr. Use of ultrasound sound imaging of jumper's knee: palellar t endinitis. Clin
in identifying tophaceous versus rheumatoid nodules Radiol 1988:39:162-165.
(letter). Arthritis Rheum 1982:25:478-479. 59. Rosenberg ZS,Feldman F, Singson RD et al. Ankle tendons:
51. Jadoul M, Malghem J, Van de Berg B et al. evaluation with computed tomography. Radiology- 1988:166:
Ultrasonographic detection of thickened joint capsules and 221-226.
tendons as marker of dialysis-related amyloidosis: a cross- 60. Beltran J, Mosure JC. Magnetic resonance imaging of tendons.
sectional and longitudinal study. Nephrol Dial Transplant Crit Rev Diagn Imaging 1990:30:111-182.
1993:8:1104-1109.
52. McDonald DG, Ueopold GR. Ultrasound B-scanning in the dif-
ferentiation of Baker's cyst and thrombophlebitis. Br J Radiol
1972;45:729-732.
C H N G 2 8
Cac mach mau nao ngoai so

Kelly S. Freed, M.D.
Linda K. Brown, M.D.
Barbara A. Carroll, M.D.
Tai bien mach mau nao th phat sau benh ly

D A N B A I x va mach mau la nguyen nhan t vong ng
hang th ba tai Hoa Ky. Nhieu nan nhan b tai
GIAI PHAU HOC ONG MACH CANH bien song sot vi nhieu mc o suy yeu than kinh.1
KY THUAT SIEU AM MACH CANH
Hn 500,000 trng hp tai bien mach mau nao
LY GIAI HNH SIEU AM ONG MACH CANH
c bao cao hang nam.2 Benh ly x va, lien
Quan sat hnh anh thang xam
quan ti ong mach canh gay hep tram trong dan
o day thanh mach mau
ti hien tng thieu mau, gay 20 en 30% trng
ac tnh mang x va
anh gia hep
hp ot qu.2 Khoang 80% tai bien do lap mach
Phan tch pho Doppler do huyet khoi, thng kem mang x va.3
Pho Doppler bnh thng Mang x va ong mach canh gay hep thng
Khao sat bang Doppler pho lien quan vi ong mach canh trong, trong vong 2
Xoa ca so pho (spectral broadening) cm t cho chia oi. V tr nay thng la v tr khao
Cac bay sat cua sieu am va cung la ni can thiep phau
Cac kieu dong chay toc o cao thuat. Lay bo mang x va ong mach canh hieu
Sieu am Doppler mau qua hn ieu tr noi khoa oi vi benh nhan co
Sieu am Doppler nang lng trieu chng khi hep ln hn 70%.4-7 Nhng so lieu
Cac bay gan ay cho thay thu thuat lay bo mang x va
Tac ong mach canh trong lam giam tai bien cung ben benh nhan khong co
Cac ky thuat trc mo oi vi benh ly trieu chng du hep hn 60%.2,8 Chan oan chnh
ong mach canh xac cua hep nang chu yeu nham xac nh e can
BENH LY ONG MACH CANH KHONG DO thiep phau thuat. Sieu am cung co the xac nh
X VA chnh xac hnh the mang x va nh mang x va
SIEU AM DOPPLER XUYEN SO
xuat huyet, la nguon goc gay nguy c lap mach do
ONG MACH OT SONG
huyet khoi.9
Giai phau
Viec chan oan benh mach mach canh thay
Ky thuat va khao sat bnh thng
oi rat nhieu trong hai thap nien qua. Sieu am
Hep di on oan gan (subclavian steal)
Hep va tac
ong mach canh phan ln thay the phng phap
TNH MACH CANH TRONG chup quang ong mach. Sieu am la phng phap
Ky thuat khong xam lan, hieu qua kinh te nham anh gia
Huyet khoi khi nghi ng nhng benh ly x va ong mach
canh. Sieu am thang xam, sieu am Doppler mau,
Doppler nang lng va Doppler pho c dung
thng quy trong anh gia benh nhan co cac trieu va ong mach canh ngoai (External Carotid Artery
chng than kinh va nghi ng benh ly nao do = ECA). ong mach canh trong (ICA) khong co
nguyen nhan ngoai so. Chup ong mach bang nhanh va ong mach canh ngoai (ECA) cung cap
cong hng t MRA (Magnetic Resonance mau cho vung mat va vung co. ong mach canh
Angiography) tr nen thong dung trong anh gia trong (ICA) co the co vung phnh ngay sau goc cua
benh ly cho chia oi cua ong mach canh va cung no.
nh trong viec lam ro cac dau hieu cua sieu am.
Chup quang ong mach c thc hien khi sieu am KY THUAT SIEU AM ONG MACH CANH
va MRA khong u e xac nh benh.
Cac ng dung khac cua sieu am mach canh Thc hien vi benh nhan nam nga, co nang hi
gom viec anh gia tieng thoi ong mach canh, cao va au quay sang oi ben vi ong mach khao
theo doi tien trien cua benh ly x va a biet,10 sat. Mot so tac gia thch khao sat khi benh nhan
anh gia trong va sau thu thuat lay bo mang x nam nghieng, mot so khac thch ngoi pha au
va,11 anh gia trc cac phau thuat ln ve mach benh nhan. au do tan so 5 en 10 MHz khi sieu
mau va xac nh nguyen nhan lap mach vong mac am thang xam, tan so 3 en 7 MHz khi sieu am
do cholesterol.12 Cac benh ly khong do x va Doppler. Viec chon la tan so chnh xac phu thuoc
cung c anh gia nh trong boc tach ong mach vao the tang benh nhan hoac cac ac tnh ky thuat
canh,13-15 loan san si-c hoac viem ong mach cua may. Sieu am Doppler mau va Doppler nang
Takayasu, anh gia xam lan ong mach canh do u lng co the thc hien bang au do tan so 5 en10
ac tnh,16,17 cac u ap vung co va cac u the MHz. Trong nhng trng hp hep nang, cac ch
canh.18,19 so Doppler nen chon la toi u e xac nh dong
chay cham.
GIAI PHAU HOC ONG MACH CANH Khao sat bang sieu am thang xam bat au
bang mat cat ngang doc theo toan bo ong mach
Nhanh ln au tien cua cung ong mach chu la canh oan co t ngay tren on hng ti goc ham
ong mach canh tay-au. ong mach nay cho (Hnh 28-2). Hng au do xuong di tai v tr
nhanh ong mach di on phai va ong mach
canh chung phai. Nhanh ln th hai la ong mach
canh chung ben trai rieng biet vi nhanh ln th ba
la nhanh ong mach di on trai (Hnh 28-1).
ong mach canh chung (common carotid
artery = CCA) i len hng sau-ngoai so vi tuyen
giap va nam sau so vi tnh mach canh va c c
on chum. ong mach nay chia oi thanh ong
mach canh trong (Internal Carotid Artery = ICA)
CAC CH NH CHO SIEU AM

ONG MACH CANH
anh gia benh nhan b thieu mau nao thoang qua,

tai bien mach mau nao
anh gia tieng thoi ong mach canh
Theo doi cac benh ly a biet
Theo doi ket qua phau thuat lay bo mang x va
Khao sat trc cac phau thuat ln cac mach mau
Hnh 28-1. Cac nhanh cua cung ong mach chu va
anh gia nguy c thuyen tac vong mac
cac ong mach nao ngoai so. A, cung ong mach chu;
anh gia cac khoi u ap vung co
In, ong mach khong ten; C, ong mach canh chung; V, ong
Theo doi boc tach ong mach canh mach ot song; S, ong mach di on; I, ong mach canh
trong; E, ong mach canh ngoai; R, ben phai; L, ben trai
Cac mach mau nao ngoai so 887
ngay tren xng on e khao sat goc cua ong ng doc. Trong hau het trng hp, mat khao sat
mach canh chung (CCA). CCA trai thng sau hn doc tot nhat thng la mat chech, nam gia mat
va kho khao sat hn ben phai. Nhan ra hanh canh tran va mat ng doc. Khoang 60% trng hp, ca
(carotid bulb) di dang cho phnh nhe gan ni chia hai nhanh chia oi va ong mach canh nam tren
oi. Mat cat ngang tai v tr chia oi cho phep nh cung mot mat phang (Hnh 28-3), trong so con lai
hng xac nh ICA va ECA va giup at c hnh thng ch ong mach canh chung va mot nhanh
anh cat doc toi u khi can phan tch pho Doppler. nam cung mot mat cat. Ghi lai hnh anh cho thay
Khi mat cat ngang cho thay benh ly x va gay tac moi quan he cua cac nhanh sau chia oi ong
nghen, co the tnh t le phan tram hep trc tiep tren mach canh vi benh ly mang x va va o kch
thc o hoac phan mem cong thc cua may trong thc mang x va theo chieu doc. Nhieu tnh
hau het cac may. chat giai phau phan biet ong mach canh chung
Da vao lo trnh ong mach canh a thay khi (CCA) va ong mach canh trong (ICA). 95% ICA
cat ngang, ta xac nh c mat phang cat doc toi nam sau-ben cua ECA. ICA thng co cho phnh
u. mot so benh nhan, mat phang doc la cat ngay sau goc cua no va co kch thc ln hn
theo mat phang tran, oi vi mot so khac lai la cat ECA. Mot trong nhng tnh chat gia tr trong nhan
dien ECA la ong mach nay co nhanh. ong
mach giap tren thng la nhanh au tien cua ECA
ngay sau cho chia oi. oi khi thay nhanh giap
tren nay xuat phat t CCA oan xa. ong mach
canh trong ICA khong co nhanh. Trong mot so
trng hp, khong thay toan bo ICA, co the ch
thay goc cua ong mach nay. Rat hiem khi khong
thay cho chia oi.20 Mot phng phap hu dung e
A xac nh ECA la go vao ong mach thai dng
nong tai vung thai dng quanh nh. Nhng dang
song ap truyen ngc ti ECA, cho hnh dang
rang ca cua song pho.
Hnh 28-2. Giai phau sieu am ong mach canh. A, Hnh 28-3. Cho chia oi ong mach canh. Khao sat
Hnh anh cat ngang phai cho thay tng quan cua ong mach doc cho chia oi cho thay ong mach canh chung, C, ong
canh chung, A, vi tnh mach canh trong, V, tuyen giap, T, va mach canh trong, I va ong mach canh ngoai, E. ong mach
c c on chum, M. Tr, kh quan, B, Cho chia oi hng len canh ngoai nho va nam trc trong va pha tren cho chia oi
so vi bau canh. ong mach canh ngoai, E, nam trc trong trong hau het trng hp. H, au benh nhan
so vi ong mach canh trong.
LY GIAI SIEU AM ONG MACH CANH day phc hp nay ln hn 0,8 mm c xem la bat
thng va co the la bieu hien cua nhng bien oi
Moi kha canh cua viec khao sat sieu am ong sm ttrong benh ly x va. o day cua thanh cua
mach canh rat co gia tr trong xac nh benh va s CCA thng tng ng vi o day ve mo hoc.22
lan toa cua benh. Trong hau het trng hp, sieu Viec o nay rat co ch va co the la phng phap
am thang xam va sieu am Doppler mau ho tr lan theo doi dien tien cua thay oi mang x va. o
nhau. Tuy nhien, neu khong co s thong nhat gia day nay lien quan ti cac nguy c tim mach bao
sieu am Doppler va sieu am thang xam, co gang gom tuoi, hut thuoc, va huyet ap tam thu. o day
xem xet nguyen nhan v sao co s khac nhau o. phc hp I-M cung lien quan ti nguy c cao phat
Ca hai cang tng ong, tnh chnh xac chan oan trien cac trieu chng tim mach benh nhan khong
cang cao. Noi chung, sieu am thang xam, sieu am co trieu chng.22
Doppler mau hoac Doppler nang lng tot trong anh gia tnh chat mang x va. Mang x
chan oan va phan o hep khi hep t, nhng benh va ong mach canh thng can anh gia ve s lan
ly tac nghen nang oi hoi sieu am pho e chan rong mang x, v tr, be mat, cau truc va anh gia
oan chnh xac. mc o hep.24 Hien tng lap mach la nguyen
nhan thong thng nhat cua thieu mau nao thoang
Quan sat hnh anh thang xam qua hn la tnh trang hep.9 Doi phan na benh
o day thanh mach. Hnh anh doc cac lp nhan b thieu mau nao thoang qua co hep nang lam
cua thanh ong mach canh cho thay hai ng tang thay oi huyet ong hoc. ieu quan trong la xac
am gan song song, ngan cach nhau bi vung phan nh cac mang x va nhe ma co the cha huyet
am kem en phan am trong (Hnh 28-4). ng khoi hoac loet co the la nguyen nhan tao hien
phan am au tien doc bien cua long mach la lp tng lap mach gay thieu mau nao hoac tai bien.1
giao dien gia lp noi mac va long mac; ng Khoang 50% en 70% benh nhan co trieu chng
phan am th hai la do giao dien cua lp gia va ban cau nao cho thay co mang x va xuat huyet
lp ngoai cua thanh mach. Lp gia cua thanh hoac loet. Nghien cu mang x va sau thu thuat
mach co am kem hoac am trong. Khoang cach lay bo mang x va cho thay xuat huyet trong
gia hai ng phan am la o day cua lp trong va mang x va la yeu to quan trong trong phat trien
gia cua thanh mach (intima-media complex). o trieu chng than kinh.24,26-32 Tuy nhien, moi quan
he gia hnh dang mang x va va khi phat trieu
chng con ang tranh cai.
Cau truc mang x va xep loai ong nhat hoac
khong ong nhat.* ong nhat co kieu phan am
cung mot mc o va be mat trn lang (Hnh 28-5).
Tnh ong nhat tng ng ve mat benh hoc la mo
* Tham khao 9, 25, 28, 33, 34
Hnh 28-4. o day thanh ong mach canh chung

bnh thng. Khao sat doc cho thay ro cac lp cua thanh.
Phan am sang au tien doc theo thanh (au mui ten) xac nh
Hnh 28-5. Mang x va ong nhat trn lang. Khao sat
giao dien long mach va lp noi mac. ng phan am th hai
doc tai cho chia oi thay thanh day trai t ong mach canh chung,
(mui ten) la giao dien cua lp gia va ngoai cua thanh mach. V,
C, ti ong mach canh trong, I (au mui ten). Cau truc am ong
tnh mach canh trong. Co cac ng phan am tng t.
nhat tng ng vi mo si lien ket day tren giai phau benh.
lien ket si ac. Mang voi hoa tao bong lng sau t long mach vao ben trong mang x va ma
va thng xay ra benh nhan khong co trieu khong b t oan (Hnh 28-8) (xem khung au
chng (Hnh 28-6). Mang x va khong ong tien pha di). Mot so e ngh xep loai mang x
nhat tng ng vi vung co nhieu mc o phan am va thanh 4 typ (xem khung th hai pha di).
khac nhau, co t nhat mot hoac nhieu vung thau am Mang x va typ 1 hoac 2 thng nhieu hn va
(Hnh 28-7). Mang x khong ong nhat tng ng lien quan ti tnh trang xuat huyet ben trong mang
ve benh hoc la loai co xuat huyet ben trong mang x va hoac co loet. Hai loai nay thng khong on
x va hoac co hien tng lang ong lipid,
cholesterol hoac cac chat cha protein.9 Sieu am
xac nh chnh xac co hay khong tnh trang xuat
huyet trong mang x va (o nhay 90% en 94%, AC TNH SIEU AM GI Y LOET
o ac hieu 75% en 88%).26, 32, 35-37 Mang x kieu MANG X VA
phomat Thu s swiss cheese vi nhieu vung
thau am la ac trng cho xuat huyet trong mang. Be mat mang x va b be hoac lom khu tru
Thc te tat ca mang x va lien quan ti xuat Vung phan am trong ben trong mang trai dai ti
long mach
huyet trong mang x. Sieu am cho thay mang x
Cuon mau ben trong mang x va
va b loet co hnh anh loi lom hoac nt tren be
mat hoac vung echo trong trong mang x va lan
HNH THAI MANG X VA
Typ 1 chu yeu thau am, vi mu mong tang am

Typ 2 oi khi thau am vi nhng vung nho tang
am
Typ 3 chu yeu tang phan am vi nhng vung nho
thau am
Typ 4 tang am ong eu
Hnh 28-6. Cac mang voi hoa (mui ten) kem bong lng
trong cac ong mach canh benh nhan khong trieu chng va
thng on nh
Hnh 28-7. Mang x khong ong nhat (gia dau +)

gan goc cua ong mach canh trong, I. Mang x nay cha Hnh 28-8. Loet mang x va. Hnh doc cua ong
nhieu vung thau am (mui ten) ac trng cho xuat huyet trong mach canh trong, I, cho thay cho lom khu tru (gia cac
mang x va. mui ten trang)
nh va la nguyen nhan gia tang kch thc dan ti am nhieu co the tao hnh anh ma trong sieu am
xuat huyet hoac hien tng lap mach.9,33 Mang x mau giong hnh anh cua loet. Tuy nhien vung co
va typ 1 hoac 2 thng gap trong nhng benh mau trong mang x va co the nhan biet la hnh
nhan co trieu chng vi hep tren 70% khau knh. anh gia bang sieu am Doppler pho co dang song
Mang x va typ 3 hoac 4 thng bao gom mo si giong dang song trong long mach. Ngc lai, dang
hoac voi hoa. Hai loai nay thng lanh tnh va on pho trong loet co dang song cong vom vi van toc
nh va thng gap benh nhan ln tuoi khong cham (Hnh 28-11).38 Mac du chan oan loet
trieu chng (xem Hnh 28-5). mang x va con nhieu tranh cai, sieu am co kha
Du sieu am xac nh xuat huyet trong mang x nang chan oan xuat huyet trong mang x va tot.
va kha tot, noi chung sieu am hay chup quang Mang x va khong eu, khong ong nhat phai
mach mau khong chng minh tnh chnh xac trong chu y v hep di 50% co the c xem la sang
xac nh mang x va b loet. Tuy nhien, cac thng phau thuat trong boi canh lam sang thch
nghien cu gan ay cho thay sieu am Doppler hp.
nang lng va Doppler mau co the ch ra nhng anh gia hep. o ng knh cua ong
om mau trong vung phan am kem cua mang x mach canh va vung hep thc hien tren mat cat
va. Khi o co the ngh ti loet (Hnh 28-9).38 ngang vuong goc vi truc mach mau.24 o tren
Mot nghien cu bao cao hnh anh dong chay kieu mat cat doc co the nhan cao mc o tram trong
nay co o chnh xac 94 % trong chan oan loet tai cua hep do chiem the tch tng phan cua mang x
phau thuat.39 Nhng nghien cu cho thay sieu am va khong ong tam. T le phan tram cua ng
co chch chat tng phan co the tang kha nang knh hep va phan tram cua dien tch hep khong
anh gia be mat mang x va. luon luon tng ong. Cac bao cao lam sang nen
Mot bay nguy hiem trong chan oan loet ghi loai phan tram hep. Hep khong oi xng hau
mang x va la do hnh anh nhieu soi gng tao nh c anh gia bang dang phan tram dien tch
hnh anh gia loet (Hnh 28-10). Mang x va phan hep,24 du ton thi gian o hn va kho khan hn ve
Hnh 28-9. Loet mang x va. ( au mui ten) Hnh Doppler mau cat doc gan cho
phat sinh ong mach canh trong co ng b khong eu cha nhng om tn hieu thap
bieu hien qua mau (mui ten), gi y dong bat thng trong vung loet.
Hnh 28-10. Gia loet. A, Hnh Doppler

mau doc cua oan gan ong mach canh
trong trai cho thay vung gia loet (mui ten)
nam sau trong mang x voi hoa, P. B, Dang
song pho trong long ong mach canh trong
tng ng hep di 50% ng knh. C,
Song Doppler pho tai vung gia loet cho
thay van toc nh tam thu tng t. Tuy
nhien, bien o cua song nho hn long ong
mach v hnh anh nhieu dang soi gng lam
giam tn hieu.
A B
Hnh 28-11. Loet mang x vi dong chay ngc van toc thap. A, hnh doc cua oan
gan ong mach canh trong cho thay mang x phan am kem, P, vi vung co dong chay ngc cham
trong loet(mui ten). B, dang song Doppler pho tai vung loet nay cho thay dong chay ngc toc o
cham ma khong thay trong trung tam long ong mach canh trong
mat ky thuat. S lan rong hai pha tren-di va

chieu dai cua mang x va nen c ghi chu.
Khi mc o tram trong cua hep gia tang, chat
lng cua hnh anh ong giam ro ret. Nhieu yeu
to anh hng trong anh gia mc o hep. Voi hoa
mang x va va cac bat thng khac tao hnh anh
bong lng, lam ngan tr quan sat long mach.
Mang x va mem thng cho hnh anh giong
dong mau chay, tao hnh anh mang x va phan
am trong hoac huyet khoi ma thng khong thay
c tren hnh sieu am thang xam. Trong hau het
cac trng hp kho, mach mau co the cho thay
mang x va nho nhng mach mau hoan toan b
tac (Hnh 28-12). Sieu am Doppler nang lng cho
thay ro trong nhng trng hp nay. V nhng ly
Hnh 28-12. Huyet khoi khong phan am. Hnh doc
do tren, sieu am thang xam thch hp cho anh gia Doppler mau cua ong mach canh trong cho thay dong chay
sang thng nhe va khong tot trong anh gia hep pha gan nhng khong thay pha xa do huyet khoi khong
mc o nang, ma loai hep nay anh gia tot bang phan am (mui ten)
sieu am Doppler pho.
chenh lech tan so v goc song ti (theta) gia chum
Sieu am Doppler pho am t au do va vector cua dong mau chay (Hnh
Hnh anh Doppler pho bnh thng. Hnh 28-13) dung e chuyen oi t o chenh lech tan so
anh Doppler pho la dang bieu o ve so lieu cua thanh van toc. o chenh lech tan so thay oi theo
cac van toc va cac hng dong mau chay c goc o Theta va tan so Doppler, ca hai yeu to tren
khao sat trong cong thu tn hieu Doppler. Du cung anh hng trong o van toc mau.
Doppler anh gia benh ly tac nghen ong mach Bieu o Doppler pho bieu dien cac van toc
canh co the thc hien dung so lieu ve tan so, tnh tren truc Y va thi gian tren truc X. Theo quy c,
toan van toc c a chuong hn.44 Cac gia tr dong chay hng ti au do co ng bieu dien
van toc co tiem nang o chnh xac cao hn o nam tren ng nen van toc 0 va dong hng
Khao sat pho Doppler. Giai thch sieu am

Doppler pho oi hoi phu thuoc vao co hay khong
co Doppler mau. Neu co sieu am Doppler mau,
ca so khao sat Doppler pho co the at tai v tr
mau bat thng. Trong trng hp sieu am thang
xam va Doppler mau bnh thng, ch can khao
sat Doppler pho mot lan tai cac v tr CCA. ECA
va ICA.
Neu khong co sieu am Doppler mau, khao sat
toan bo mach mau bang sieu am pho vi cong
khao sat m rong bang ng knh mach mau. Sau
o thu hep ca so Doppler ti mc toi thieu (1,5
mm3) va khao sat Doppler pho ve tan so hoac van
Hnh 28-13. Dang song bnh thng cua ong mach toc. Vi s ho tr tot cua sieu am Doppler mau,
canh chung. Goc Theta (mui ten) gia hng chum am thi gian thc hien sieu am pho toan bo ong mach
(ng cham) va vector dong chay nen at t 30 en 60 o. canh giam ang ke. o van toc dong chay va phan
tch pho Doppler cac v tr pha trc, ngay tai va
ra xa khoi au do co ng bieu dien nam di. pha sau vung thay hep nhat va cach quang moi
e de dang phan tch ng bieu dien, Doppler 1cm tnh t v tr mang x va ti khi khong the
pho co the ao ngc ng nam di len nam khao sat ong mach canh trong. at v tr cong thu
tren ng nen. Luon nh hng chay that cua tn hieu song song vi thanh mach mau e xac nh
mach mau. Cng o cua moi van toc (so lng goc Theta, t o co the tnh gia tr van toc dong
cua te bao mau vi moi thanh phan van toc) bieu chay bang chuyen oi cac thong tin t tan so thu
hien bang o sang cua ng bieu dien. ay cung c (Hnh 28-13). Goc Theta la goc gii han bi
c biet la cach ve s o van toc tren sieu am ng thang t au do Doppler vi chieu dong
thang xam. Trong ong mach canh bnh thng, mau chay. Goc Theta ly tng la bang 0, tng
pho tan so hep trong tam thu va thng rong hn ng vi cosine bang 1, se thu c tn hieu tot nhat
trong au va cuoi tam trng. Thng co mot ve chenh lech tan so. Tuy nhien, goc o nay kho
vung en gia ng bieu dien pho va ng nen co the at c khi khao sat. Do o, gia tr cua
c goi la ca so pho spectral windows.45,46 goc Theta chap nhan c la t 30 en 60 o trong
Cac nhanh ong mach canh trong va ngoai cua sieu am Doppler pho ong mach canh. Khi goc nay
ong mach canh chung (CCA) co dang song khac vt qua 60 ti 70 o, tnh chnh xac cua so lieu ve
biet (Hnh 28-14). ong mach canh ngoai (ECA) chenh lech tan so hay van toc giam ro ret, neu goc
cung cap mau cho vung c mat co khang lc cao o bang 90 se tng ng vi khong ghi nhan dong
do vay dong chay giong cac ong mach ngoai bien chay. Toan bo mach mau cua CCA va ICA nen
khac. ong mach canh trong (ICA) cung cap mau khao sat vi goc Theta giong nhau neu co the. Noi
cho nao co khang lc thap, giong cac ong mach chung, ch can khao sat goc cua ong mach canh
cung cap mau cho cac tang co chuyen hoa cao nh ngoai ECA v mang x va gay tac v tr nay t
gan, than va nhau. Tnh chat chung cac dang song gap hn ong mach canh trong ICA va hiem khi co
cua ong mach khang lc thap la mot lng ln gia tr lam sang. Tuy nhien nen ghi nhan neu co
cua dong chay hng ti trong tam trng. Dang hep v co the o la ly do gay tieng thoi vung co
song cua CCA la tong hp cua ICA va ECA nhng trong khi ICA bnh thng.
hau nh CCA co dang song giong ICA va dong Xoa ca so pho. Mang x va nho vao trong
chay tam trng thng tren ng nen. Khoang long ong mach lam dong chay theo lp cua cac te
80% dong chay hng t CCA qua ICA ti nao; bao hong cau chay roi. Cac te bao hong cau di
20% qua ECA e vao c vung mat. S giam tng chuyen vi van toc khac nhau nhieu, do vay dang
oi cua dong chay ti ECA se tao dang song cng pho se rong hn lam au ca so pho mau en.
o thap hn trong dong chay cua CCA va ICA. Hien tng nay goi la xoa ca so pho spectral
A B
Hnh 28-14. Dang song pho bnh thng. A, ong mach canh ngoai ECA, cho thay dong chay
toc o thap tam trng (mui ten) cho thay tuan hoan khang lc cao. B, ong mach canh trong ICA co
dong chay tam trng cao lien quan ti khang lc thap cua mach mau nao. C, ong mach canh chung
CCA dang song la s ket hp cua ECA va ICA. Dong chay hng ti au do (mui ten) va pho Doppler
nam tren ng nen. Trong A va B, dong chay ngc khoi au do. Du pho nay b lat ngc at tren
ng nen, van toc am tnh (mui ten cong) cho ngi oc biet hng that cua dong chay.
broadening (Hnh 28-15 va 28-16). Xoa ca so tnh toan ve nh lng, cac dau hieu ve xoa ca
pho se gia tang t le vi mc o hep cua ong so pho va s khong ong nhat mau trong sieu am
mach canh va so lng te bao mau c ghi nhan mau la mot tien oan tot cho roi loan dong chay.
e thu thap thong so.44,47-49 Mot so may sieu am Cac bay. Xoa ca so pho gia tao co the do loi
pho cho phep ngi ieu khien o o rong cua pho ky thuat nh cai at gain qua cao. Trong trng
(bandwidth) gia van toc ln nhat va be nhat va hp nay nen quanh song pho thng b nhieu. Khi
anh gia c hien tng xoa ca so pho. Tnh gia nghi ng co xoa ca so pho, nen giam thap gain e
tr cua cac phep o nay c chng minh va tuy thay co phai co ca so pho hay khong. Mot
nhien can cac nghien cu sau hn e ghi nhan moi nguyen nhan khac la do s dch chuyen cua thanh
quan he gia thong so ve nh lng xoa ca so mach khi cong thu tn hieu at qua rong hoac at
pho vi tng mc o hep.49 Tuy nhien, neu khong v tr qua gan thanh mach. e tranh hien tng
nhanh ICA, ECA t CCA.50 Dong chay roi cung co

the xay ra ni co s thay oi ot ngot khau knh
mach mau. V du, thay tai hanh canh (carotid
bulb), la ni tan cung cua CCA trc khi chia thanh
ICA va ECA.11
Khuynh hng xoa ca so pho gia tang t le
trc tiep vi van toc mau cua dong chay. V du,
no co the thay trong ECA bnh thng, ong mach
cot song, va trong CCA cung cap tuan hoan bang
he cho oi ben do tac ICA. S gia tang van toc
co the gay dong chay roi oi khi thay trong cac
van ong vien tre vi the tch tong mau tim bnh
thng hoac trong benh nhan co gia tang the tch
tong mau tim. Tnh trang nay co the gap trong ro
Hnh 28-15. Hep 40% en 59% ong mach canh
ong-tnh mach va d dang ong-tnh mach.11,51
trong, ICA. Kieu dong chay toc o cao trong mach mau hep.
Van toc nh tam thu ( 126 cm/giay). Van toc tam trng bnh Xoa ca so pho sau mo lay mang x va co the
thng. W, ca so pho. ton tai vai thang do long mach con hep hoac benh
tai phat. ieu nay co the do s thay oi trong
trng lc thanh mach.
Cac ong mach canh uon khuc co the bieu
hien xoa ca so pho va vung mau chay toc o cao
khong oi xng du khong co mang x va. Nhng
nguyen nhan khac khong do x va gay dong chay
roi trong ong mach canh gom phnh ong mach,
boc tach ong mach va loan san c-si.
Xoa ca so nen co the do benh mach mau, tuy
nhien s tng quan cua sieu am thang xam va
Doppler mau co the xac nh nguyen nhan xoa ca
so pho. Ca so pho bnh thng ket hp vi ky
thuat Doppler ung an giup tranh c cac bay
trong chan oan.
Kieu dong chay van toc cao. Hep ong
mach canh thng lam thay oi van toc khi hep
Hnh 28-16. Hep 80% en 99% ong mach canh qua 50% khau knh (70% tiet dien).1 S gia tang
trong, ICA. Van toc nh tam thu la 558 cm/giay. Chu y xoa van toc thng tang theo mc o hep. Tai cac v
ca so pho (mui ten) cho thay dong chay xoay tng ng vi
tr hep nang (tren 95%), van toc o c co the
hep tram trong. Van toc tam trng (138 cm/giay) cung tang
bat thng vi hep nay. Lat ngc ngha la dong chay ri xa giam va dang song co the b cong vom.43,52 Trong
au do; song pho lat ngc va nam tren ng nen e de phan trng hp nay, can oi chieu sieu am Doppler
tch. mau va Doppler nang lng e chan oan chnh
xac o tram trong cua hep. Van toc gia tang khu
tru tai hep va ngay sau hep, viec at cong thu tn
xoa ca so trong trng hp nay, can giam kch hieu tai cac v tr nay la rat quan trong. Di chuyen
thc cong thu Doppler va at ngay gia dong xa khoi v tr hep, dong chay bat au tai lap hnh
chay. thai bnh thng neu khong co sang thng hep
Cac kieu dong chay thay oi co the gap tai khac pha xa.
mot so v tr cua he ong mach canh nhng la Cac c tnh sieu am ng knh hep cua ICA
bnh thng. V du, thng thay s tach dong xep t 0 en 50%, 50% en 60%, 60% en 80% va
chay tai v tr mach mau phan nhanh nh cac 80% en 99%. Mc o hep da tren sieu am thang
xam va cac thong so Doppler xung, bao gom van Mc o hep cua ong mach canh tren lam
toc nh tam thu PSV (peak systolic velocity) cua sang benh nhan co hoac khong co trieu chng
ICA, van toc cuoi tam trng EDV (end diastolic bung phat. Trc ay cac hep di 50% cho rang
velocity) cua ICA, PSV cua CCA, EDV cua CCA, quan trong, t le phan tram nay cung nh cac trieu
t le van toc nh tam thu cua ICA/CCA, va t le chng lam sang thu thap a thay oi. Hoi phau
van toc cuoi tam trng cua ICA/CCA. Van toc thuat lay bo mang x va ong mach canh tren
nh tam thu chng minh chnh xac hep mc o benh nhan co trieu chng vung Bac My
nang.41,44 Moi quan he cua ch so nay vi mc o NASCET va Hoi phau thuat ong mach canh
hep rat ro rang va de dang xac nh. Tai vien cua chau Au ECST cho rang ky thuat lay bo mang
chung toi, cach tnh la van toc nh tam thu cua x va rat co ch hn ieu tr noi khoa oi vi
ICA nho hn 125 cm/giay tng ng vi hep di benh nhan co hep t 70% en 99% ICA co trieu
50%, van toc 125 en 250 cm/giay tng ng hep chng.4,5 Mc o hep c xac nh bang quang
50% en75%, ln hn 250 cm/giay tng tng hep ong mach trong ca hai nghien cu va dung hai
75% en 80%. T le van toc cuoi tam thu rat hu tieu chuan khac nhau. Trong NASCET, phan tram
ch trong chan oan phan biet hep mc o nang. hep xac nh bang so sanh ng knh long cho
Khong co tieu chuan thiet lap trong anh gia hep hep va ng knh bnh thng oan xa cua ICA.4,5
ong mach canh ngoai ECA. Mang x va gay Trong ECST, ng knh ICA bnh thng c
hep lien quan ti ECA t gap hn trong ICA va c oan tai v tr hep.
khong quan trong tren lam sang. Do vay tieu Cac ket qua cua NASCET va ECST anh gia
chuan van toc dung anh gia hep ECA khong c cac ch so Doppler e suy luan t cac ch so van
thiet lap. Tuy nhien, nguyen tac la khao sat 2cm toc nay ra tng ng chnh xac cac hep bang hoac
gan va 2cm xa cho hep tai oan gia cua CCA, ke tren 70%. Cach nay cung tieu chuan hoa hoac xac
tiep la khao sat t le van toc khao sat tai v tr 2 cm nh cac ch so Doppler hoac ket hp cac ch so
trc va sau cho hep tng t khi khao sat ong nay e xac nh hep tren 70%. Hau het cac tac gia
mach ngoai bien. Khi van toc tang gap oi tai v ong y ch so duy nhat la PSV cua ICA55 du cac
tr khao sat se tng ng t nhat hep 50% va t le ch so khac nh t so cua PSV cua ICA/CCA co o
van toc vt qua 3,5 tng ng hep tren 75%. nhay va chuyen biet cao (Bang 28-1).56 Tuy nhien,
Trong khi sieu am Doppler pho van la phng cac nghien cu bao cao PSV cua ICA t 130cm/sec
phap chan oan chnh xac mc o hep cua ICA, ti 325 cm/giay tng ng vi hep ICA tren 70%
sieu am Doppler mau va gan ay sieu am Doppler tai cac vien khac nhau. Khoang rong nay cua PSV
nang lng gop phan quan trong cho chan oan cung co y kien cho rang cac phong sieu am rieng
chnh xac va hieu qua. Sieu am Doppler mau va biet phai xac nh cac thong so Doppler chnh xac
Doppler nang lng co the dung e c tnh mc cho thiet b cua ho. S tng quan cua khoang van
o hep cua ECA va ICA. toc bang sieu am vi mc o hep xac nh bang
BANG 28-1
PHAN TCH PHO DOPPLER
Khau knh Ty so van toc Ty so van toc nh Van toc nh tam thu Van toc nh
hep nh tam thu cuoi tam trng cuoi tam trng
Cua ICA/CCA Cua ICA/CCA
0 - 40% < 1,5 <2.6 < 110 cm/giay < 40 cm/giay
> 25 cm/giay < 40 cm/giay
41% - 59% < 1,8 < 2.6 > 120 cm/giay > 40 cm/giay
60% - 69% >1,8 > 2.6 > 150 cm/giay > 70 cm/giay
70% - 79% > 3,0 > 3.3 > 210 cm/giay > 100 cm/giay
80% - 99% > 3,7 > 5.5 > 280 cm/giay
< 25 cm/giay
Tac Dong chay nho mot ben
CCA
Khong co dong hoac dong
chay ngc gan cho tac
quang ong mach can thiet e at c s ket qua sac la do s ket hp cua ca hai o chenh lech tan
chnh xac va hieu qua cho phong sieu am rieng so trung bnh cua hong cau va goc Doppler theta.
biet. Neu mach mau khuc khuyu hoac chia nhanh, goc
nay se thay oi theo truc mach mau, gay ra thay
Sieu am Doppler mau oi mau ma khong co s thay oi trong van toc
Sieu am Doppler mau cho biet thong tin ong bang hong cau. Hn na, s phan bo mau se ao ngc
hnh anh hoac mot vung c la chon khao sat trong cac mach mau khuc khuyu khi truc cua
(Hnh 28-17). Cac cau truc mo mem co nh khong chung thay oi tng oi theo au do ma hng
co phase hoac chuyen dch tan so c dung lam dong chay khong oi. Cac phan mach mau song
gia tr bien o va hien th di dang thang xam vi song vi chum am Doppler tng ng goc ti theta
dong chay mau chong len. o chenh lech tan so 90 o, se khong co o chenh lech tan so va khong
Doppler trung bnh tao bi cac te bao hong cau tao thu c tn hieu mau.
xung qua v tr cong khao sat; o chenh lech nay Can thc hien cac khao sat Doppler mau vi
tnh theo cong thc tng ng t ong (auto- o nhay dong chay va cai at gain toi u. Mau nen
correlative) hoac phan tch di chuyen dang vet lap ay toan bo long mach nhng khong lan ra mo
(speckle motion analysis). Viec phan bo mau phu mem ke can. Cac tan so pulse repetition PRF va
thuoc vao chieu dong chay so vi au do. Dong toc o hnh nen cai at e cho phep thay cac hien
chay hng ti co mot mau va dong chay hng i tng dong chay trong mach mau. Toc o hnh se
co mau khac. Cac mau nay la t y va thng cai thay oi bang thay oi cong thu tn hieu mau va o
at theo kieu : mau o la dong chay ong mach va sau khao sat. Vung mau khao sat cang ln th toc
mau xanh la tnh mach. o bao hoa mau bieu th o hnh cang cham. Khao sat mau tai v tr cang
cac van toc khac nhau cua dong chay. Bong mau sau th PRF cang thap. o nhay Doppler mau nen
nhieu (deepler shades) thng ch van toc cham ieu chnh e khao sat c cac van toc; v du
trung tam quanh ng nen (baseline) vi van toc trong sang thng ong mach canh gan gay tac,
bang 0. Khi van toc tang len, bong mau sang len nen khao sat vi cong khao sat mau nho va cai
va co nhieu dang mau khac nhau. Mot so thiet b thang mau thap (xem Khung trang 898). Tuy
cho phep cac o chenh lech tan so chon loc c nhien, hien tng vt ngng xay ra vi toc o
bieu dien vi mau khac biet nh xanh la cay. Tnh thap v lam giam PRF. Ngoai cac thay oi cua
chat mau xanh nay cung cap c oan ong s PRF, toi u goc Theta, gain, va cai mc nang
hien dien cua dong chay toc o cao. Cai at thang lng, giam o loc thanh va tang thi gian khao
mau Doppler co the tao ra hnh anh gia do vt sat co the dung e lam toi u khao sat dong chay
ngng tng ng vi dong chay toc o cao ben cham.
trong mach mau (Hnh 28-18). S phan bo mau Dong chay tr nen thay ro trong sieu am mau
Hnh 28-17. Hnh mau cat doc bnh thng ni

Hnh 28-18. Hien tng vt ngng trong trung
chia oi cua ong mach canh. Vung mau xanh cua
dong chay ngc( mui ten) xuat hien au tam thu hoac nh tam mach mau vi dong chay lp nhanh nhat (mui
tam thu va sau o thay oi theo tam trng, I, ICA; C, CCA; ten). Hnh anh Doppler dong chaycua ong mach canh
E, ECA. trong.
TOI U HOA VIEC XAC NH VAN TOC

DONG CHAY CHAM
Giam toc o khao sat ( v du giam PRF)

Goc Theta cang nho cang tot ( nho hn 60)
Phan loc tn hieu thap
Tang o lien tuc
Tang thi gian khao sat
Tang o khuyech ai
Hnh 28-19. Hep mc o nang. Hnh anh Doppler doc

hoac sieu am nang lng cho thay tnh thong
cua ong mach canh trong (ICA) cho thay lng ln mang x
thoang cua long mach (Hnh 28-19). ieu nay cho va, P, va phan con lai nho cua long mach (mui ten) kem
phep xac nh truc that cua mach mau, biet cho at vung trang cho thay van toc cao.
cong Doppler va xac nh van toc tin cay hn. Hn
na, Doppler mau giup phan tch pho Doppler de
dang nh nhanh chong xac nh vung co dong chay
bat thng. o chenh lech van toc cao nhat co the
xac nh bang hien tng vt ngng cua Doppler
mau. Doppler mau giup xac nh v tr at cong
thu tn hieu pho vung co mau bat thng nhat.
Co the xac nh hien dien hep bang s thay oi
mau hoac vung hep thay c. Neu hep tao tieng
thoi, rung mo quanh mach mau co the tao mau lom
om vung mo mem, thay ro trong tam thu (Hnh
28-20).58,59 So sanh Doppler mau vi sieu am pho
va quang mach mau cho thay tnh chnh xac, o
Hnh 28-20. Hnh anh mau gia quanh mach mau
nhay va o chuyen biet tng oi giong nhau.60,61
pha xa ni hep ICA (au mui ten). Cho khu tru pha tron
Tuy nhien, Doppler mau cho thay nhieu li iem mau o va xanh trong mo mem quanh mach mau (mui ten)
(xem Khung trang 899). Doppler mau lam giam do rung ong cua mo tao bi dong chay xoay trong long
thi gian khao sat nh ch ra cac v tr mau bat mach.
thng cho sieu am pho khao sat. Nhan dien de
dang cac nhanh cua ECA e phan biet vi ICA. mau xac nh c ban chat dong chay nay. Tuy
Cac thong tin dong chay ong tren mot vung khao nhien, khi khong co dong chay ngc nay co the la
sat ln tao mot cai nhn chung cua bat thng dong dau hieu sm cua benh ly x va.62 Dong chay
chay va xac nh truc mach mau Hn na Doppler ngc tai cho chia oi nay khac biet ro ret vi hien
mau tang t tin va tnh hieu qua trong chan oan tng vt ngng. Mau o va xanh bao hoa ke
va tranh cac bay chan oan. Dong chay lp bien nhau vi dong chay cham cua dong chay ngc so
mat tai ni chia oi ong mach canh, tai o co s vi nhieu mau sac khac nhau va sat nhau trong
ao ngc dong thoang qua bnh thng oi hien tng vt ngng. Dong chay xoay cua
dien vi ni phat sinh cua ECA (Hnh 28-17). CCA co the la dau hieu gian tiep cua hep gan
Doppler mau bieu hien s tach biet dong chay bnh nhng cung co the la thay oi bnh thng.
thng di dang mot vung ao dong nam doc Doppler mau ch ra hnh chay xoay khong eu theo
theo thanh ngoai cua hanh ong mach canh, xuat sau cua CCA.
hien sm trong ky tam thu hoac nh tam thu va Doppler mau co the giup tranh cac bay chan
ton tai trong mot thi gian thay oi sang mot phan oan. Cac thay oi trong sinh ly tim mach, cac ton
cua th tam trng.62,63 S ao dong nay tao dang thng noi tiep nhau, benh ly ong mach canh oi
song Doppler bat thng rong, tuy nhien Doppler ben, loan nhp, cac thay oi sau mo va cac mach
anh thang xam trong khi o phan giai Doppler thap

CAC U IEM CUA HNH ANH hn sieu am Doppler pho. o bao hoa mau khong
DOPPLER MAU the tng ng vi van toc.58 Hnh anh mau ung
cho mot goc va do vay cac thay oi trong bao hoa
Giam thi gian khao sat mau co the n gian ch phan anh thay oi hng
Nhanh chong xac nh cho hep/van toc cao tren
mach mau va goc o Doppler. He thong mau vi
song pho
tnh hoa van toc trung bnh tao iem anh mau
Tang kha nang chan oan va s t tin
Phan biet tac t dau hieu ng ch (string sig)n
(color pixel) trong hnh anh. Tuy nhien, ngi
tot hn Doppler pho khao sat thng anh gia van toc toi a, do vay
Cung cap ong thi thong tin huyet ong hoc va sieu am Doppler pho can thiet anh gia chnh xac
giai phau hoc cua hep gay thay oi huyet ong hoc nang.
Thong tin dong chay ve van toc va hng dong chay
Tang tnh chnh xac trong xac nh mc o hep Sieu am Doppler nang lng
Lam ro cac khac biet tren Doppler xung
Tn hieu mau cua Doppler nang lng tao t pho
mau Doppler. Bien o phan am tao o sang va
tone mau cua tn hieu mau. Bien o nay phu
thuoc vao mat o hong cau tai v tr khao sat.
KHUYET IEM CUA HNH ANH DOPPLER Doppler nang lng dung bang rong vi t le tn
MAU DONG CHAY hieu va nhieu tot hn Doppler mau. V Doppler
nang lng khong anh gia tan so ma anh gia
Phu thuoc vao goc Theta- co the tao anh nhieu bien o hoac nang lng nen rat oc lap vi goc
o phan giai kem hn sieu am thang xam Theta. Cac tnh chat nay tao cho Doppler nang
t thong tin hn sieu am Doppler pho lng rat nhay khi khao sat dong chay dang ch tai
Toc o khung hnh cham hn vung nghi ng tac ong mach canh. Cung co gia
thuyet Doppler nang lng tot hn Doppler mau.
Da vao tnh chat tren, Doppler nang lng rat tot
khao sat mc o hep. Doppler nang lng cung
mau ngoan ngoeo co the dan ti anh gia sai mc tot trong anh gia be mat mang x va (Hnh 28-
o hep. Trong cac trng hp nay, Doppler mau 21). Du nhieu li iem, Doppler nang lng khong
co the cung cap cac hnh anh trc tiep cua s thong cung cap thong tin ve van toc va hng dong
thoang long mach tng t nh quang ong mach.64 chay.68 Hn na, Doppler nang lng rat nhay vi
Thc te, quang ong mach cho hnh anh long mach s dch chuyen.
mau, nhng khong cho hnh anh thanh mach, ca
Doppler mau lan Doppler nang lng co kha nang
Cac bay
anh gia hep hoan hao hn quang mach mau. Hn
Du xac nh van toc chnh xac rat gia tr trong chan
na, v Doppler mau bieu th cac kieu dong chay
oan hep, ton thi gian neu cac so o khong tin
nen de dang phan biet cac hau qua huyet ong hoc
cay. S thay oi sinh ly tim mach co the anh
khu tru do ton thng. Doppler mau co gia tr ac
hng tren van toc. V du, van toc tao do hep
biet trong khao sat cac kenh con lai nho cua dong
trong benh nhan cao huyet ap se cao hn benh
chay vung cua hep nang ong mach canh.60,61,64-66
Doppler nang lng cung mang u iem tng nhan thng. Mat khac, giam cung lng tim se
lam giam van toc trong tam thu va tam trng.
ng va tren ly thuyet rat nhay trong khao sat
dong chay van toc cham cng o thap. Doppler Loan nhp, ton thng van ong mach chu va
mau va nang lng co kha nang phan biet cac benh c tim nang co the lam thay oi ro dang
khac biet cua hnh anh va sieu am Doppler pho song ong mach canh va lam thay oi van toc
tang tnh chnh xac va t tin. trong tam thu va tam trng (Hnh 28-22). Dung
Du CDU co nhieu thuan li, CDU van phu bm bong ong mach chu cung lam thay oi dang
thuoc vao goc Theta va hnh anh nhieu nh vt pho. Cac thay oi tren co the khong co gia tr
ngng.67 o phan giai cua CDU t hn cua hnh anh gia hep. V du, nhp tim cham lam tang the
A
B
Hnh 28-21. Loet. A, Hnh anh Doppler nang lng cua oan gan ong mach canh trong ben
phai cho thay vung loet (mui ten) trong vung cua mang x va, P, tnh mach canh, F, hnh anh
Doppler gng (mui ten cong). B, Hnh chup mach mau cho thay loet tai vung tng t.
CAC LI IEM CUA SIEU AM MAU

DOPPLER NANG LNG
Khong xay ra hien tng vt ngng

Tang o chnh xac trong anh gia hep
Giup trong phan biet sang thng hep va tac
Mo ta tot hnh thai be mat mang x va
Tang o nhay trong khao sat van toc cham bien o
thap
Khong phu thuoc goc Theta
Hnh 28-22. H ong mach chu nang. Dang song pho

CAC BAT LI CUA SIEU AM MAU DOPPLER CCA ben trai cho thay dang dong chay roi vi dong chay
NANG LNG tam trng ngc va mat dong chay cuoi tam trng.
Khong cho biet hng hoac van toc dong chay

hp kho ac biet khi thiet b co chc nang quay
Rat nhay vi cac di chuyen( o phan giai thi gian ngc-xem cineloop playback. Chc nang Cine
kem) loop cho phep lu lai hn 10 giay cua Doppler mau
va khao sat xong va co the xem lai tng hnh mot.
ieu nay giup trong anh gia tnh thong thoang
tch nhat bop, gay tang van toc nhng lam keo dai cua long mach. Cac ton thng tac trong ong
thi ky tam trng. Benh nhan vi hep nang van mach canh co the anh hng van toc oi ben. V
ong mach chu co the thay dang pho bat thng du, hep ICA nang mot ben hoac tac nghen co the
bao gom keo dai thi gian tang toc, giam van toc gay tang dong chay he thong oi ben. ieu nay
nh, dai o doc len nh (upstroke) va dang pho gay tang gia bu tr van toc oi ben, ac biet vung
vom. Tuy nhien, hep ong mach chu va hoac nhe co hep (Hnh 28-23).72 Ngc lai, hep oan gan
thng t dan ti bat thng tren sieu am.71 Tnh CCA hoac ong mach khong ten co the lam giam
trang khong tng ng cua hnh anh va Doppler dong chay dan ti hau qua lam giam ca van toc o
canh bao kha nang co bay trong chan oan. c mot cho hep xa vi ni tac.
Doppler mau co the dung e vt qua trng Ty so van toc tai ICA vi CCA cung ben co
CAC NGUYEN NHAN KHIEN HNH ANH VA

DOPPLER KHONG TNG NG
Roi loan nhp tim

Benh van tim, benh c tim
Hep ong mach chu nang
Tang hoac tut huyet ap
Cac ton thng ke tiep nhau
Hep ong mach canh oi ben
Hep nang ong tam tren oan dai
Boc tach ong mach canh
Ton thng gan tac
Mach mau uon khuc
Mang x voi hoa, phan am kem hoac phan am trong
Cac bien the giai phau
hnh anh hoc Doppler dong mau khong co gia tr

trong viec tranh cac bay lien quan ti ng bieu
dien pho Doppler bu tr.
Du hep nang se lam gia tang van toc ngay tai
hoac pha xa mang x va, cac ton thng ke tiep
nhau gay tac quan trong noi so hoac ngoai so co
the gay giam chenh lech van toc va tao song ICA
khang lc cao khong ien hnh. Phai khao sat cac
Hnh 28-22. Hep nang trong ong mach canh
mach mau cang xa ve hng nao cang tot e tranh
trong (ICA) ben trai (oi ben) tao gia tang van toc bu
tr ICA ben phai. A, Van toc nh tam thu tang ro sau bo sot ton thng ke tiep pha xa. Dong chay
hep ICA ben phai ( 358cm/giay), tng ng 80% en 99%. ngay sau cho hep tren 95% thung dep hoac co
Van toc nay khong gia tr v hep nang cua ICA oi ben lam dang tardus parvus va van toc giam (Hnh 28-24).
tang dong chay ben phai. B, Hnh anh Dopler cat doc cua Hep mach mau nang, nhat la loai hep quanh chu vi
hep trung bnh tai goc ICA ben phai, O, cho that mang x
tren mot oan dai co the tao ra song dep ma khong
va kch thc trung bnh pha trc va long mach cha ay
mau( mui ten). Tnh khong ong nhat sau vung hep cho thay co o chenh lech tan so cao. Du khong co s gia
vung chay xoay lien quan ti hep va hien tng vt ngng tang ve van toc trong oan hep dai ve ng knh
v van toc cao. Chup mach mau xac nh hep ICA ben phai nh vay, thng thay ro xoa ca so pho va dong
(40% en 59%). chay roi pha xa cho hep nh the. Ngoai ra, hep
dang thoi thng c phat hien tren hnh anh thi
the giup tranh mot so bay.44 Gia tr rieng biet la t gian thc ac biet neu dung sieu am mau.
le van toc tam thu tai ICA/ CCA49,73 va t le van Mot nguyen nhan sai sot khac trong sieu am
toc cuoi trng tai ICA/CCA.54 T le van toc tng xung la hien tng vt ngng (aliasing) xay ra
ng vi mc o hep a ra trong Bang 28-1. Gia do khong co kha nang phat hien van toc nh that
tr thu thap trong ICA phai lay ngay tai hoac pha s v t le cong thu tn hieu rat thap. Mot v du cua
xa cho thay hep nhat hoac cho bat thng sieu am vt ngng thay trong phim anh phng Tay, co
pho/ sieu am Doppler mau. Gia tr thu thap trong hien tng chay ngc banh xe cua oan xe keo
CCA phai lay gan trc cho phnh cua hanh canh. khi hien tng quay banh vt qua toc o hnh.
Phai luon luon lap ty so cac van toc mot khi van Chenh lech tan so toi a khao sat c khong vt
toc CCA cao hoac thap bat thng hoac khi van qua 50% cua PRF (pulse repetition frequency).
toc ong mach canh chung hai ben khong oi Vi hien tng vt ngng, cac nh cua pho van
xng. Nh a ban ve xoa ca so pho phan trc, toc b cat va a xuong di ng nen (Hnh 28-
Hnh 28-24. Dang song van toc thap kieu

tardus-parvus (mui ten) thay trong ICA ben
trai pha xa cho hep hn 95%
25). Neu vt ngng xay ra, au do song lien

tuc phoi hp duplex co the khao sat van toc that.
Hien tng nay c khac phuc bang cach tang
goc theta (goc ti cua song Doppler), nh o lam
giam chuyen dch tan so phat hien c hoac bang
cach giam tan so song ti. Gia tang PRF la tang
o chenh lech tan so nhng tang PRF lam gii han
chieu sau mach mau va tan so trung tam cua au
do.24,46 Ngi khao sat co the di chuyen ng nen
len xuong e thu thap van toc chnh xac, khong
cho hien tng vt ngng xay ra, la sap xep lai
khoang van toc trong cac benh nhan hep nang.
Vt ngng oi khi co li trong khi ly giai hnh
anh; vt ngng co the lam noi bat tnh tram
trong cua dong chay roi cung nh tnh thong
thoang cua long mach.
Hnh 28-25. Aliasing. Van toc cao vt qua na tan so lap

Tac ong mach canh trong (ICA)
lai xung (PRF) b cat cut (mui ten) va b ha xuong xuat hien
Tac ong mach canh c chan oan khi khong co di ng nen (mui ten cong) theo chieu ngc lai. Cac au
dong chay trong mach mau. oi khi, nhp ap lan tn hieu vt ngng hng ve pha ng nen (mui ten m),
truyen trong ICA tac co the giong dong chay bat ieu nay trai nghch vi hnh anh song khi ao dong thc s.
thng trong mach mau thong thoang. Nen at
cong thu tn hieu pho trong long mach va nhan ra ti mc gan nh chay nho giot. Rat kho xac nh
dong chay co nhp ap. Can chu y ky en chieu dong chay con lai nho trong long mach b tac khi
cua dong chay va ban chat cua nhp ap. Muon anh gia bang hnh anh thang xam, nhat la khi
khao sat dong chay ngay trung tam nen xac nh mang x va hoac huyet khoi co phan am trong
tren mat cat ngang va kch thc cong cang nho hoac khi co mang x va voi hoa can tr viec khao
cang tot. Nhp ap t ngoai hiem khi c truyen sat.
vao trung tam huyet khoi.40 Trong hep tram trong (> 95%), cai at Doppler
Khi hep nang gan tac, tia chay toc o cao giam mau che o nhay chuan co the khong thay c
Hnh 28-26. Dong chay con lai manh nh si ch

(mui ten) ben trong mot cho hep kht cua ong mach canh
trong (ICA). Hnh cat doc tren Doppler mau cua ICA
dong chay con lai nho nh si ch. Do vay can cai

at che o Doppler nhay vi dong chay toc o
thap e phan biet hep nang va tac (Hnh 28-
26).61,64 PDU vi o nhay cao e khao sat cac tn
hieu cng o thap va van toc cham co the
thaydong chay nho. Sieu am Doppler nang lng
vi o nhay tang khi phat hien cac tn hieu bien
o thap, van toc thap c s dung e thay c
hnh anh dang ch cua dong con lai. Sieu am
Doppler mau co o chnh xac 95% en 98% trong
phan biet hep nang vi tac hoan toan tren quang
mach mau khi s dung cac thong so ky thuat thch
hp.74,75
Co the biet c hep nang hoac tac ICA qua
quan sat bang sieu am Doppler mau va pho CCA
cung ben (Hnh 28-27). Dang song Doppler xung
trong CCA va ICA oan gan ton thng thng cho
tn hieu khong oi xng va khang lc cao vi dong
chay tam trng giam hoac mat hoac ao ngc
ngoai tr khi co tuan hoan bang he cua ECA ti
tuan hoan nao. Tng t, CDU hoac PDU co the
thay mau loe len trong tam thu nhng giam ro hoac
mat tn hieu trong tam trng; khi so sanh oi ben
thay ro.74,75 Chan oan tac va hep nang dang ch
bang Doppler mau va Doppler namg lng chnh Hnh 28-27. Tac ong mach canh trong (ICA). A,
xac hn thang xam co pho duplex va co the loai bo Hnh anh thang xam cat doc cua ICA cho thay huyet khoi
chup quang mach trong viec khang nh tac ICA a choan ay trong long ICA (mui ten), gi y tac. B, Hanh canh.
B, Sieu am Doppler mau cho thay dong chay ngc (mau
c sieu am chan oan.74,75
xanh) ngay trc (mui ten) ton thng ma khong thay dong
Mot bay khac trong chan oan tac ICA hoan chay trong long mach tai v tr ton thng, co ngha la tac. C,
toan la nham lan ECA thong thoang hoac mot Dang song pho cong vom trong CCA trc ton thng. Chu
trong cac nhanh cua ECA vi ICA. Tnh huong y dong chay tam trng giam ro ret (mui ten) cho thay khang
lc cao.
gay kho khan khi he thong bang he cua ECA va
ICA do ap ng vi benh ly ICA lau dai va ECA Con tiep
Hnh 28-27, tiep theo. D, Dang pho thap cong vom tai
trc cho hep cua ong mach canh trong (ICA), ve pha tren
va di ng nen, chng to dong hai chieu.
DAU HIEU SIEU AM CUA TAC

ONG MACH CANH TRONG
ong mach canh ngoai cung ben co dang song ong

Hnh 28-28. Dang song khang lc thap trong ECA,
mach canh trong
E, cho thay tuan hoan bang he ti nao quanh ICA b tac.
Khong thay dong chay trong ICA bang CDU, PDU,
Chu y tang dong chay cuoi tam trng (mui ten).
sieu am pho
Dong chay ao ngc trong oan ICA hoac CCA
trc oan tac
Huyet khoi hoac mang x lap ay long ICA tren tac CCA thng khu tru. Dong chay van thng
hnh thang xam, CDU, PDU duy tr ECA va ICA nh mot ong mach se co
Dang song khang lc cao trong CCA cung ben hoac dong chay ngc. Sieu am la phng phap c
oan gan ICA chuong e anh gia s duy tr dong chay quanh ni
chia oi ong mach canh sau khi CCA b tac.
Thong thng dong chay ngc trong ECA cung
cap mau cho dong chay ti trong ICA cung ben.
co dang song khang lc thap (Hnh 28-28). Mot ky oi khi gap dong chay theo hng ngc lai (Hnh
thuat giup nhan dien ECA bang cach sieu am tai 28-31).40,77,78
ni phat sinh mach mau nay ong thi go nhe ong
mach thai dng. Go ong mach thai dng nong Cac chien lc tien phau cho cac benh
thng tao hnh anh bien dang song pho cua ECA nhan vi benh ly ong mach canh
(chiem 80% cac khao sat) (Hnh 28-29).76 Tuy Cac cong viec tien phau cua benh ly canh lien
nhien, phai that than trong khi dung phng phap quan vi bang ket qua cua NASCET, ECST va
nay v co the thay ap ng tren ca CCA lan ICA, Nghien cu X va ong mach canh khong co
mac du t thay hn so vi ECA (54% va 33%).76 trieu chng ACAS ( asymptomic carotid
Cac nhanh mach mau cua ECA co tnh chat giong atherosclerosis study)79 va viec phat trien cac ky
nhau, dung phan biet vi ICA. CDU co the giup thuat hnh anh khong xam lan. Trong khi nhieu
xac nh cac nhanh nay (Hnh 28-30). Ket hp ngi xem chup quang mach la tieu chuan vang,
kch thc mach mau, v tr, dang song, cac cac phe bnh ky thuat nay bao gom cac thay oi
nhanh, va phan ng vi go ong mach thai quan trong gia cac nha quan sat va yeu to cho
dng e xac nh ECA. rang quang mach anh gia thap mc o hep. Thc
Tac ICA co the co tao lap huyet khoi pha xa, te viec so sanh chup mach mau va sieu am cua
Hnh 28-30. ong mach canh trong, I, va ong

mach canh ngoai, E, nam pha tren cho chia oi.
Hnh cat doc tren Doppler cho thay de dang cac nhanh cua
ECA (au mui ten)
Hnh 28-29. Ky thuat go xng thai dng. ng
bieu dien pho Doppler cua ong mach canh ngoai (ECA) cho
thay bien oi song Doppler dang rang ca, T, tao ra do thu
thuat go ong mach thai dng.
Hnh 28-31. Tac ong mach anh chung CCA. Hnh anh cat doc tren
Doppler tai ni chia oi ong mach canh ben trai cho thay dong chay ngc trong
ong mach canh ngoai ECA va dong chay hng ti trong ong mach canh trong
ICA benh nhan b tac hoan toan ong mach canh chung CCA.
hep ong mach canh cho thay cac so o sieu am sieu am va chup quang mach trong viec phat hien
tng oi gan nhau vi ket qua phau thuat.80 Sieu va xac nh mc o hep. Tng t sieu am, MRA
am chng to la phng phap chnh xac cao trong co the cho thay ro hnh the mang x va va them
chan oan hep nang cung nh phan biet hep tram na la co the anh gia tuan hoan trong nao. MRA
trong va tac, ac biet t khi xuat hien sieu am co the hu ch trong cac tnh huong nh mang x
Doppler mau va Doppler nang lng. Hien nay, va voi hoa che lap mat long mach khi sieu am.
MRA cho thay tnh chnh xac co the so sanh vi Nhieu nha ieu tra e ngh viec thay chup
A
B
Hnh 28-32. Loan san si c. A, Hnh cat ngang cua cho chia oi cua ong mach canh ben
trai cho thay cho khuyet mau phan am kem (mui ten) vung phnh khong kem dau vt ngng
mau do van toc tang. Khoi phan am kem lam bien dang nhe dong chay. B, Chup quang ong
mach xac nh cho thieu mau tai cung v tr (mui ten) do huyet khoi co the lien quan benh loan san
si c ngi n tre. Sieu am theo doi mot thang sau ieu tr chong ong cho thay hnh anh hanh
canh bnh thng.
mach mau tien phau bang ket hp sieu am va mach thai dng hoac thay oi do tia xa co the lam
MRA. Ho cho rang dung chup mach mau chi khi thanh mach day ong tam lan toa va thng xay ra
MRA va sieu am khong tng ong trong ket qua ong mach canh chung (CCA).88
hoat ket qua khong ay u. Cac nghien cu khac Chan thng cot song co co the tao boc tach
ung ho viec s dung sieu am canh mot mnh trc hoac phnh mach. Boc tach ong mach canh co
khi phau thuat. Nhieu nghien cu cho thay hn the xay ra t phat do di chng benh ly mach hoac
90% cac oi tng phau thuat co the c anh gia benh x va khong co benh s chan thng ro.89
ay u bang lam sang va sieu am. Tuy nhien, neu Khao sat sieu am cua boc tach ong mach canh co
nghi ng benh oan gan cung ong mach chu, the thay la noi mac tang am di ong hoac co nh,
hoac nghi co tac hoan toan, mot so ung ho chup kem theo huyet khoi hoac khong. Hnh anh thng
mach mau trc mo. khong tng ng gia thang xam va Doppler lien
quan ti dong chay bat thng (Hnh 28-33). Sieu
BENH LY ONG MACH CANH KHONG DO am Doppler hoac nang lng co the lam sang to v
X VA sao khong tng ng qua hnh anh giam dan ot
ngot dong mau trong long mach ti iem tac, giong
Benh ly nay t xay ra hn loai do mang x va. vi dau hieu trong chup quang mach. Du thng
Loan san c-si (fibromuscular dysplasia = FMD), xay ra tac ICA, thay mat dong chay khang lc
dien tien khong viem vi s tang san c va si cua cao tai oan gan CCA, dong chay trong ICA co the
thanh mach tach biet bang nhng vung bat thng co van toc cao vi long hep th phat sau xuat
fragmentation, thng xay ra ICA hn cac oan huyet va huyet khoi trong vung co long gia. Tng
khac. Ngi ta a mo ta ac tnh hnh dang chuoi ng, dang song cua CCA co the bnh thng hoac
hat thay tren hnh quang mach. Ch co mot vai b e cong dep. MRA cho thay huyet khoi trong
bao cao ve dau hieu sieu am cua FMD.86,87 Nhieu c, xac nh chan oan boc tach. Du chup quang
benh nhan b FMD khong co dau hieu bat thng mach thng dung au tien e xac nh boc tach,
ac trng hoac ro ret. FMD co the khong co trieu sieu am c dung e theo doi anh gia ap ng
chng hoac co the gay boc tach mach hoac gay lap ieu tr vi ieu tr chong ong. Cac khao sat theo
mach (Hnh 28-32). Viem ong mach do t mien doi ap ng ieu tr nay co the cho thay hien tng
nh viem ong mach Katayasu hoac viem ong tai lap dong chiem 70% trng hp.90-92 Chan
Hnh 28-33. Boc tach va tac nghen. A, Dang song khang lc cao bat thng (mui ten) tai
goc cua ICA ben phai khong co dong chay pha xa v tr nay (mui ten cong). B, anh gia bang
hnh thang xam vung tac ch thay ng phan am (mui ten) khong co hep nang do x va. C,
chup hnh ong mach sau o cho thay hnh anh nho dan ti v tr tac (mui ten) lien quan boc
tach ong mach ong mach canh va tac do huyet khoi.
oan boc tach rat quan trong nh la nguyen nhan ni chia oi (Hnh 28-34). Doppler nang lng co
cua cac trieu chng than kinh, ac biet khi dau the dung quan sat hien tng gay tac hoac boc
hieu lam sang, tuoi va benh s khong ien hnh tach u the canh. Cac khoi u ngoai mach nh
cho benh ly mang x va hoac tai bien xuat huyet. hach lympho, tu mau hoac ap xe chen ep hoac lam
U the canh, mot trong nhieu paraganglioma (u di lech ong mach co the chan oan phan biet vi
can hach) vung au va co thng lanh tnh, co vo u mach mau nguyen phat nh phnh mach hoac gia
bao ro nam tai v tr chia oi cua ong mach canh. phnh mach. Co the phan biet gia phnh mach sau
Nhieu u co the hai ben, nhieu mach mau va tao chan thng vi phnh ong mach canh that bang
tieng thoi. Nhieu u nay tao ra catecholamines gay dau hieu song TO and FRO tai co cua gia phnh
tang huyet ap ot ngot trong va sau mo. Sieu am cung nh thay oi ben trong, dau hieu ying-yang
Doppler mau cho thay khoi u nhieu mach mau tai ac trng cua gia phnh mach (Hnh 28-35).
SIEU AM DOPPLER XUYEN SO

CAC DAU HIEU SIEU AM TRONG
BOC TACH ONG MACH CANH TRONG Trong sieu am Doppler xuyen so (trascranial
sonograph = TCD), dung au do tan so thap 2 MHz
ong mach canh trong ICA anh gia dong chay ong mach canh trong so va
Tac / khong co dong chay he thong ot song-nen va vong Willis. Ca so
Lanoi mac tang am +/- huyet khoi e khao sat la cac hoc mat, lo cham ln va thng
Huyet khoi giam am +/- hep long mach nhat la vung xng thai dng mong (ca so
Hnh dang bnh thng xuyen thai dng).93 Tuy nhien, nhieu benh nhan,
ti 55% trong mot nghien cu,94 khong the tm
ong mach canh chung CCA
c ca so khao sat TCD vi ket qua ly giai
Dang song khang lc cao
Dong chay b cham lai c. Phu n, ac biet la phu n My goc Phi, co
Bnh thng xng thai dng day, song am kho xuyen qua e
ti c cac ong mach nen so.94,95 Cac kho khan
Hnh 28-34. U the canh. A, Hnh anh cat ngang qua ni chia oi ong mach canh co khoi
phan am kem (mui ten) vi vai not voi (mui ten). Hnh Doppler mau cho thay tuan hoan rai rac
ben trong khoi u (mui ten m). B, Sieu am Doppler nang lng cho thay tuan hoan tang ro (mui
ten) khi so sanh vi cach cai at chuan Doppler dong mau.
nay han che ng dung hnh anh hoc TCD nh la

mot phan thng quy cua khao sat mach mau nao
khong xam lan.94
Dung sieu am pho, khao sat cac thong so khac
nhau nh van toc trung bnh va van toc nh tam
thu hoac cuoi tam trng, ch so sc ap va ch so
khang lc cua mach mau. Doppler mau hoac
nang lng co the cai thien cac khao sat van toc
qua cung cap thong tin xac nh goc Theta va nh
v lo trnh cua mach mau.93 TCD co nhieu ng
dung gom anh gia cac hep trong nao va tuan
hoan bang he, xac nh va theo doi tnh trang co
mach do xuat huyet di nhen, xac nh chet nao,
va xac nh d dang ong-tnh mach.95-98 TCD la
phng phap hieu qua trong chan oan hep ong
mach nao gia vi o nhay cao ti 91%. TCD t
hieu qua trong xac nh hep cua he thong ot
song-nen, ong mach nao trc-sau va nhanh tan
cua ICA.95,96 Tuy nhien TCD, tot trong anh gia
tnh thong thoang cua ong mach ot song va
hng dong chay khi khong ghi nhan dong chay
cua ong mach ot song oan ngoai nao (Hnh 28-
36). Chan oan hep trong nao da vao s gia tang
van toc trung bnh cua dong chay trong mach mau
ton thng, so sanh vi mach mau oi ben cung
mot v tr.95,96
Cac u the cua TCD la tnh tien li may co
nhieu ni, dung theo doi cac nguy c bien chng
mach mau benh nhan tai phong mo hoac phong
chup mach mau.96 Co the dung TCD trong mo khi
boc au do at tai xng thai dng giup anh gia
ong mach nao gia trong phau thuat lay bo mang
x va ong mach canh. anh gia tuan hoan nao
khi ong mach canh b kep.96 TCD cung co kha
nang chan oan tnh trang lap mach nho trong mo
tao hnh anh nh nhon cng o cao tren pho
Doppler. Ky thuat nay co the dung anh gia lien
tuc tnh trang co that mach. Chan oan nay thng
da tren hang loat khao sat cho thay s gia tang
tng oi van toc dong chay va thay oi ch so
khang lc do giam kch thc long mach do co that
mach mau.96
ONG MACH OT SONG

Hnh 28-35. Gia phnh mach. A, Hnh anh cat ngang
cua oan xa CCA ben trai, C, cho thay dang song ti va lui ong mach ot song cung cap phan ln tuan hoan
(to and fro) ac trng (mui ten cong) vung co cua gia phnh nao sau. Thong qua vong Willlis, chung co the
mach ln, P, xay ra sau khi at tnh mach trung tam. B, Sieu
cung cap tuan hoan bang he cho vung khac cua
am mau mode nang lng cho thay ro hn co dai (mui ten)
trai t CCA, C, ti gia phnh mach, P. V, tnh mach canh. nao trong trng hp tac ong mach canh. anh
Hnh 28-36. Hnh anh Doppler xuyen so.

A, Doppler pho xuyen so qua ho sau benh
nhan co hep khong hoan toan oan gan cua
ong mach di on cho thay dong chay tam thu
ngc (mui ten) va dong chay tam trng hng
nao (mui ten cong). Khao sat quet hnh theo mat
A cat ngang t lo cham ln (au mui ten m). B,
Hnh anh Doppler mau cung benh nhan cho
thay dong chay ngc xay ra khong ch bent
rong ong mach di on ma ca ben trong ong
mach nen (mui ten)
gia ong mach ot song oan ngoai so bang sieu duplex con ang c nghien cu. Vai tro trong
am duplex va Doppler mau luon theo sau khao sat chan oan hep ong mach di on oan gan a
ong mach canh.100,101 Tuy nhien, ngi ta a c xac nh ro rang.20,64,104,105 t s dung sieu am
khong nghien cu ky cac ong mach nay nh duplex ong mach ot song trong anh gia hep,
ong mach canh. Cac trieu chng cua thieu mau boc tach hoac phnh mach.
ong mach ot song-nen cung thng khong ro
rang va kho xac nh, so vi trieu chng cua tuan Giai phau
hoan ong mach canh. Kho tm thay s tng quan ong mach ot song thng la nhanh au tien cua
gia ton thng va v tr. Hn na, cac thay oi ong mach di on (Hnh 28-37). Tuy nhien,
giai phau, kch thc nho, nam sau va nam di thng gap cac thay oi tai ni phat sinh cua ong
mom ngang lam kho khao sat chnh xac ong mach mach ot song. Trong 6% en 8% trng hp,
ot song bang sieu am.101-103 ng dung sieu am ong mach ot song ben trai xuat phat trc tiep t
Hnh 28-38. ong mach ot song bnh thng, A,

va tnh mach, V. Hnh cat doc tren Doppler cho thay ong
mach va tnh mach ot song chay gia mom C2-C3 co bong
lng cach khoang (mui ten)
e xac nh hng chay cua ong mach ot

song.104
Hnh 28-37. Lo trnh cua ong mach cot song (mui Hng au do xuong pha chan cho phep thay
ten). No chay doc qua lo cac mom ngang ot song (au mui goc ong mach ot song 60% en 70%, 80% ben
ten) va noi vi ong mach ot song oi ben tao thanh ong phai va 50% ben trai. S khac biet nay la do ong
mach nen, B. C, ong mach canh; S, ong mach di on.
mach ben trai nam sau hn va xuat phat trc tiep
t cung ong mach chu 6-8%.
cung ong mach chu gan vi ong mach di on Can xac nh s hien dien va chieu cua dong
trai. Trong 90% dan so, oan gan ong mach ot chay. Nen khao sat cac mang x va thay c.
song chay hng len tren-trong, qua pha trc cua ong mach ot song cung cap mau cho nao vi ch
mom ngang cua C7 va i vao lo mom ngang cua so khang lc thap vi dong chay lien tuc trong tam
C6. Phan tram con lai, ong mach ot song vao lo thu va tam trng tng t vi CCA, tuy nhien co
mom ngang C5 hoac C7 va hiem khi C4. Kch hnh thai song rat a dang ngay oi vi nhng
thc cua ong mach ot song thay oi, ben trai mach mau thay bnh thng tren quang mach.109 V
ln hn chiem 42% trng hp, bang nhau trong mach nay nho va dong chay khuynh hng cho pho
26% trng hp va 32% ben phai ln hn.106 Bam rong. Ca so pho thay ro trong he ong mach canh
sinh co the ch co mot ong mach ot song. bnh thng , khong ro oi vi ong mach ot song
(Hnh 28-39).40
Ky thuat va khao sat bnh thng Tnh mach ot song (thng la am roi) chay
Tren Doppler mau, thay c ong mach ot song song song va dnh vi ong mach ot song. Can
trong 92% en 98% ( Hnh 28-38).102,107 Doppler than khong nham lan vi ong mach nhat la khi
mau giup phat hien de dang ong mach ot song dong chay co tnh ap. So sanh dong chay tnh
nhng khong lam tang t le khao sat.103 Khao sat mach trong khi th co the phan biet c. Co the
duplex ong mach ot song c thc hien bang nham nhanh co len cua than co-giap vi ong
xac nh CCA trc tien tren mach cat doc. Xac mach ot song. Co the tranh ieu nay bang cach
nh hng dong chay CCA va tnh mach canh. xac nh cac moc mom ngang kem theo ong mach
Quet au do t t hng ra ngoai e xac nh ot song va dang song. Nhanh co len co dang
ong va tnh mach ot song chay gia cac mom khang lc cao giong ong mach canh ngoai.104
ngang t C2 en C6 , cac mom nay xac nh bang Khao sat Doppler xuyen so he thong ong
cac bong lng cach khoang. Mat cat ngang vi mach ot song-nen co the thc hien vi khao sat
Doppler mau cho phep ngi khao sat thay ong ngoai so. Khao sat bang au do 2 MHz vi t the
mach canh va tnh mach canh cung luc va dung no benh nhan ngoi ap au do di cham, hoac t the
Hnh 28-39. Dang song pho Doppler bnh thng

cua ong mach ot song. Dang khang lc thap giong nh
ong mach canh chung va canh trong. Ca so pho co the b
xoa (mui ten)
nam nga ap au do sau chum. Doppler mau hoac

nang lng giup the hien he thong ot song-nen
xuyen so.
Hep ong mach di on (subclavian

Hnh 28-40. Kieu huyet ong hoc trong s o hep
steal) oan gan ong mach di on. Ton thng gay tac
Hien tng lay trom (steal phenomenon) di oan gan ong mach di on trai (mui ten nho) lam giam
on xay ra khi co hep nang hoac tac oan gan dong chay ti oan xa ong mach di on, S. ieu nay tao
ra dong chay ngc (mui ten ln) xuong ong mach ot song
ong mach di on hoac ong mach canh tay-
ben trai, L, va lay trom mau t ong mach ot song ben
au vi ong mach ot song hai ben bnh thng. phai, R va cac mach mau noi so khac trong nao thong qua
ong mach cua chi b thieu mau lay trom mau t vong Willis, W.
tuan hoan ot song-nen qua dong chay ngc trong
ong mach ot song va co the tao ra trieu chng
thieu mau ong mach ot song-nen (Hnh 28-40). mach di on.
Cac trieu chng thay ro khi van ong chi tren hoac anh gia bang Doppler ong mach ot song
thay oi t the au. Tuy nhien khong s tng cho thay bon dang song bat thng tng ng vi
quan ro ret gia trieu chng cua ong mach ot benh ly ong mach di on va ot song tren chup
song-nen va hoi chng lay trom di on nay. mach mau. Bon dang bao gom trom toan bo, trom
Thong thng, dong trong ong mach than nen mot phan, trc trom va dang song vom tardus
khong b anh hng tr khi ong mach ot song parvus.112 Trong lay trom toan bo, dong chay
tham gia vao viec trom nay b hep nang.96,110 trong ong mach ot song ao ngc hoan toan
Hn na, tai tao mach mau hoac phau thuat co the (Hnh 28-41). Lay trom mot phan cho thay dong
khong lam giam trieu chng.111 Hoi chng hep chay trong ong mach ot song ch ao ngc
ong mach di on thng do benh ly x va, du thoang qua trong th tam thu (Hnh 28-42).96,110,113
chan thng, lap mach, mo, bam sinh hoac yeu to Lay trom khong hoan toan tng ng vi hep nang
tan sinh co the la nguyen nhan. Hep hoac tac oan ong mach di on hoac khong ten ch cha tac.
gan ong mac di on co the kho thay nhat la Mot cach khao sat la van ong tay 5 phut hoac
ben trai, bat thng dang song ong mach ot song dung may o huyet ap e tao huyet ap cao ben co
tng ng vi o tram trong cua benh ly ong ton thng e thay ro cac dau hieu sieu am va co
Dang song bat thng cua

ong mach ot song
Hep hoan toan ong mach di on

Dong chay ngc trong ong mach ot song cung
ben vi ong mach di on hoac khong ten b
hep hoac tac
Hep khong hoan toan

ao ngc dong trong ong mach ot song thoang
qua trong th tam thu
Co the chuyen thanh lay trom mau toan bo khi
lam nghiem phap tang van ong
Gi y ton thng hep nhng khong tac
Hnh 28-41. Dong chay ngc trong ong mach
Hien tng trc hep
ot song, chan oan co hien tng lay trom tc
Dang song au tho Bunny: dong chay tam thu
hep ong mach di on. Pho Doppler ao ngc do
giam thap hn dong tam trng
vay dong chay hng nao phai chieu ben tren ng nen neu
chieu dong chay bnh thng.
Co the chuyen sang dong chay ngc mot phan
khi tang van ong
Gap khi hep oan gan ong mach di on
Dang song keo dai va cong vom tardus-parvus

Thay trong hep ong mach ot song
Hnh 28-42. Hep oan gan ong mach di on khong hoan toan. A, Dong
chay trong au tam thu (au mui ten) hng ti; dong chay nh tam thu (mui ten la hng
ngc; va dong chay cuoi tam thu va tam trng (mui ten) la hng ti. B, Sau nghiem
phap tang van ong, lng dong chay ngc trong nh va cuoi tam thu tang (mui ten).
Hnh 28-43. Hep nhe presteal. Dang pho Doppler

trong ong mach ot song cho thay giam nh tam thu (mui
ten) benh nhan co hep nhe presteal. Hep khoang 50%
Hnh 28-44. Tac ICA hai ben va tang tuan hoan trong
ng knh oan gan ong mach di on trai
ong mach ot song. Dang pho cua ong mach ot song
the chuyen t trom mot phan thanh toan bo.86,105 trai cho thay dong chay roi toc o cao (mui ten). Trong khi tang
van toc va dong chay roi co the co hep khu tru, trong trng
Trc ao presteal hoac dang song au tho hp nay co tang van toc ong mach ot song
bunny cho thay dong chay ti nhng giam van toc
cuoi thu nho hn cuoi tam trng va thay trong
benh nhan co hep di on oan gan (Hnh 28- dong chay bnh thng chay roi trong ong mach,
43).112 Dang song nay co the chuyen thanh song xoa ca so pho khong la dau hieu cua hep. o
ao mot phan hoac hoan toan khi lam nghiem van toc khong tin cay cho hep v co thay oi ln
phap the duc. Dang song vom tardus parvus co the ng knh ong mach ot song. Du van toc cao
thay benh nhan co hep nang oan gan ong hn 100 cm/giay thng do hep, chung co the van
mach ot song.110 bnh thng tren hnh quang mach. V du, van toc
Vi hep di on, sieu am Doppler mau co the cao co the do bu tr khi tac ong mach canh (Hnh
cho thay hai mach mau co mau tng t nhau gia 28-44).108 Do vay, s gia tang khu tru van toc t
mom ngang bieu th ong mach va tnh mach ot nhat 50%, thay hep tren thang xam hoac
song.64 Hnh anh cat ngang cua ong mach ot Doppler mau hoac dang song vom la nhng dau
song tren sieu am Doppler mau cho thay dong hieu hep ongmach ot song co y ngha. Do s a
chay ngc so vi CCA.101 Song Doppler pho can dang cua ch so khang lc tren ong mach bnh
dung e phan biet dong chay ngc trong ong thng hoac bat thng nen khong the dung lam
mach va song tnh mach ap.64,104 dau tien oan benh.
Chan oan tac ong mach ot song kho.
Hep va tac Thng khong thay dong chay do bam sinh khong
Chan oan hep ong mach ot song kho hn chan co ong mach hoac do khao sat kho ve ky thuat.
oan ao ngc dong. Hep co anh hng huyet Chan oan phan biet gia hep nang vi tac kho do
ong thng xay ra tai ni phat sinh ong mach cung nguyen nhan. Hn na, van toc dong chay
nam sau trong phan ngc tren va co the thay trong vom trong hep nang va giam so lng hong cau di
khoang 60% en 70% so benh nhan.102,107,108 Ngay chuyen qua vung khao sat khien cho bien o tn
ca khi thay c ni phat sinh ong mach, van co hieu Doppler qua thap khong the phat hien
the kho khan trong viec ieu chnh goc Doppler c.103 Doppler nang lng co the tot trong
e o van toc chnh xac v v tr sau va mach khuc trng hp nay. Khi ch thay c mot tnh mach,
khuyu. Khong co mot tieu chuan chnh xac hieu rat nghi ng hien dien tac ong mach hoac bam
qua cho anh gia hep ong mach ot song. Khi sinh khong co ong mach.
TNH MACH CANH TRONG
Tnh mach canh trong la tnh mach ln chc nang

dan lu mau t nao. Ch nh lam sang thong
thng nhat cho sieu am Doppler mau va pho tnh
mach canh la anh gia nghi ng tac tnh mach
canh do huyet khoi.114-121 Tao lap huyet khoi co
the lien quan ti at catheter tnh mach trung tam.
Cac ch nh khac bao gom gian tnh mach
canh122-125 va hng dan at cannul tnh mach canh
hoac di on126-128 ac biet trong tnh huong kho
khi giai phau mach mau bien dang.
Ky thuat
Tnh mach canh trong bnh thng de thay. Khao
sat tnh mach vi co ngc len va au nghieng mot
pha oi ben. Mat cat ngang va doc vi ap lc nhe
vung co tranh lam xep tnh mach. Mat cat tran t
ho tren on e khao sat oan di cua tnh mach
canh trong va oan gia cua tnh mach di on
khi chung noi nhau tao nen tnh mach canh tay
au.
Tnh mach canh nam me trc ngoai cua
CCA, ben cua tuyen giap va sau hn so vi c c
on chum (xem Hnh 28-2). Tnh mach co thanh
tang am ro net va long co phan am kem hoac
trong. Thng thay mot van oan xa.117,119,129 Hnh 28-45. Tnh mach canh bnh thng. A, Nhp
Tnh mach canh phai thng ln hn ben trai.124 ap tnh mach phc tap tnh mach canh tng ng vi chu
Sieu am thi gian thc cho thay tnh ap tnh ky tim phai. B, Trong nghiem phap Valsalva, ap lc ben
trong long ngc tang lam giam lng mau ve tim va tnh
mach va do tim phai co bop cung nh thay oi mach canh trong J, phnh ln ra. C, CCA
ng knh tnh mach do thay oi ap lc trong long
ngc. Khao sat Doppler cho thay kieu dong chay
(Hnh 28-45). Khi ht vao, ap lc am trong long
ngc tao dong chay hng tim va tnh mach canh
giam ng knh. Khi th ra hoac khi lam nghiem co the khong ro lap tc. Huyet khoi tnh mach
phap Valsalva, ap lc trong long ngc tang lam canh co the khong co trieu chng lam sang v v tr
giam mau tr ve va tnh mach to, khong ghi nhan sau cua tnh mach va co he thong bang he. Tnh
hoac dong chay yeu. Thanh cua tnh mach canh trang nay trc ay c chan oan bang quang
xep hoan toan khi e au do vi ap lc trung bnh. tnh mach, mot phng phap xam lan thc hien khi
Nhay mui ot ngot lam giam ap lc trong ngc, tao nghi ng cao. Ky thuat khong xam lan nh sieu
xep quan tnh cua tnh mach tren sieu am thi gian am, CT va MRA, huyet khoi tnh mach canh c
thc, kem theo gia tang ngan dong chay tnh mach chan oan nhieu hn. Huyet khoi tnh mach canh
ve tim khi khao sat Doppler.116,118-120 thng do bien chng cua at catheter tnh mach
trung tam.115,119,120 Cac nguyen nhan khac la
Huyet khoi nghien ma tuy qua ng tnh mach, phau thuat
Tnh chat lam sang cua huyet khoi tnh mach canh vung co, tnh trang tang ong, u trung that va
bao gom khoi u hoac vung sng vung co khong ro viem nhiem khu tru/hach.117 Mot so trng hp
kho xac nh va cang chac. Chan oan chnh xac khong ro nguyen nhan hoac t phat.118 Bien chng
Hnh 28-46. Huyet khoi tnh mach canh. Hnh Doppler Hnh 28-47. Huyet khoi tnh mach canh man vi
cat doc cho thay dong chay (mui ten) tren huyet khoi phan am, dong chay tnh mach tang trong tuan hoan bang he
T. (mui ten cong). Hnh anh Doppler cat ngang. Huyet khoi phan
am day (mui ten) lap gan ay long mach. Cac kenh nho tai lap
cho thay dong chay (mui ten m)
co the la viem tac tnh mach tu mu, di chuyen cuc Sieu am chng to la phng tien tin cay trong chan
mau ong va lap mach phoi.117-121 oan huyet khoi tnh mach canh va tnh mach di
Khao sat thi gian thc114-121 cho thay tnh on, co thuan li hn CT va MRI v khong mac
mach khong b ep , thay huyet khoi phan am trong tien, tien li, khong phong xa, khong can chat can
long mach. huyet khoi cap co the co phan am quang. Sieu am gii han khao sat va khong chup
trong hoac khong the phan biet vi mau chay, tuy het hnh tnh mach canh va di on, nhat la oan
nhien thieu ac tnh ep mach va mat Doppler mau nam sau xng di ham hoac pha di xng
trong vung co huyet khoi giup chan oan chnh on. Tuy nhien, biet c o lan rong cua huyet
xac. Hn na, mat phan ng tnh mach vi nhp khoi khong thng la yeu to quan trong trong ke
th va tnh ap tnh mach. Sieu am Doppler mau hoach ieu tr.117,121 Khao sat sieu am hang loat
va pho khong thay dong chay (Hnh 28-46). Tnh anh gia vi ap ng vi ieu tr sau anh gia lan
mach bang he co the xac nh (Hnh 28-47), ac au. Hn na sieu am co the ghi lai tnh thong
biet trong huyet khoi man. Hoa long trung tam thoang trc khi at ng mach, giup at catheter
hoac khong ong nhat cua huyet khoi ngh ti man chnh xac va an toan hn.
tnh. Huyet khoi man co the kho thay v chung co
khuynh hng to chc va kho tach biet vi mo m
phan am quanh mach mau.119 Mat pha tim-ho hap THAM KHAO
trong tnh mach canh va di on thong thoang co 1. Carroll BA. Carotid sonography. Radiology - 1991; 178: 303 -
the thay huyet khoi khong gay tac nghen. Xac 313.
2. Executive Committee for the Asymptomatic Carotid
nh mat tnh ap tnh mach hai ben co ngha Atherosclerotic Study. Endarterectomy for asymptomatic carotid
huuyet khoi hng trung tam, co the xac nh bang artery stenosis. JAMA 1995; 273(18): 1421 - 1428.
quanh tnh mach hoac MRA. 3. Fontcnelle L. T, Simper SC, Hanson TL. Carotid duplex scan
versus angiography in evaluation of carotid artery disease. Am
Huyet khoi lien quan ti at catheter thng 5Mrg - 1994; 60: 864 - 868.
thay tai au catheter du co the thay bat c ni 4. North American Symptomatic Carotid Endarterectomy Trial
nao. Thay catheter di dang hai ng tang am Collaborators. Beneficial effect of carotid endarterectomy in
symptomatic patients with high - grade carotid stenosis. TV
song song ngan cach nhau bi vung phan am trong. EnglJMed 1991; 325: 445 - 453.
Dong chay thng khong thay trong long catheter 5. European Carotid Surgery Trialists' Collaborative Group. MRC
ngay ca khi catheter thong thoang. European Carotid Surgery Trial: interim results for symptomatic
patients with severe (70 to 99) and mild (0 to 29) carotid stenosis. 27. Leahy AL, McCollum PT, Feeley TM et al. Duplex
Lancet 1991; 337: 1235 - 1243. ultrasonography and selection of patients for carotid
6. Neale ML, Chambers JL, Kelly AT et al. Reappraisal of duplex endarterectomy: plaque morphology or luminal narrowing? J
criteria to assess significant carotid stenosis with special Vase Surg 1988; 8: 558 - 562.
reference to reports from the North American Symptomatic 28. Reilly LM, Lusby RJ, Hughes L et al. Carotid plaque histology
Carotid Endarterectomy Trial and the European Carotid Surgery using real - time ultrasonography: clinical and therapeutic
Trial. J Vase Surg 1994; 20: 642 - 649. implications. Am J Surg 1983; 146: 188 - 193.
7. Chang YJ, Golby AJ, Albers GW. Detection of carotid stenosis. 29. Persson AV, Robichaux WT, Silverman M. The natural history of
Stroke 1995; 26: 1325 - 1328. carotid plaque development. Arch Surg 1983: 118: 1048 - 1052.
8. Derdeyn CP, Powers WJ, Moran CJ et al. Role of Doppler US in 30. Lusby RJ, Ferrell LD, Ehrenfield WK et al. Carotid plaque
screening for carotid atherosclerotic disease. Radiology 1995; hemorrhage: its role in production of cerebral ischemia. Arch
197: 635 - 643. Surg 1982; 117: 1479 - 1488.
9. Merritt CRB, Bluth El. The future of carotid sonography. AJR 31. Edwards JH, Kricheff II, Gorstein F et al. Atherosclerotic
1992; 158: 37 - 39. subintimal hematoma of the carotid artery. Radiology - 1979;
10. Ricotta JJ. Plaque characterization by B - mode scan. Surg Clin 133: 123 - 129.
North Am 1990; 70(1): 191 - 199. 32. Imparato AM, Riles TS, Gorstein F. The carotid bifurcation
11. Gerlock AJ, Giyanani VL, Krebs C. Applications of Noninvasive plaque: pathologic findings associated with cerebral ischemia.
Vascular Techniques. Philadelphia: WB Saunders Co; 1988: 147 - Stroke 1979; 10: 238 - 245.
159. 33. Gerovlakas G, Ramaswami G, Nicolaides A et al.
12. Taylor KJW. Clinical applications of carotid Doppler ultrasound. Characterization of symptomatic and asymptomatic carotid
In: Taylor KJW, Bums PN, Wells PNT, eds. Clinical Applications plaques using high - resolution real - time ultrasonography. Br J
of Doppler Ultrasound. New York: Raven Press: 1988: 120 - 161. Surg 1993; 80(10): 1274 - 1276.
13. Bluth El, Shyn PB, Sullivan MA et al. Doppler color flow 34. Holdsworth RJ, McCollum PT, Bryce JS et al. Symptoms,
imaging of carotid artery dissection. J Ultrasound Med 1989; 8: stenosis and carotid plaque morphology. Is plaque morphology
149 - 153. relevant? EurJ Vase Endovasc Surg 1995: 9: 80 - 85.
14. Hennerici M, Steinke W, Rautenberg W. High - resistance 35. Sterpetti AV, Schultz RD, Feldhaus RJ et al. Ultrasonographic
Doppler flow pattern in extracranial carotid dissection. Arch features of carotid plaque and the risk of subsequent neurologic
A/euro/1989; 46: 670 - 672. deficits. Surgery 1988; 104: 652 - 660.
15. Rothrock JF, Lim V, Press G et al. Serial magnetic resonance and 36. Weinberger J, Marks SJ, Gaul JJ et al. Atherosclerotic plaque at
carotid duplex examinations in the management of carotid the carotid artery bifurcation: correlation of ultrasono - graphic
dissection. Neurology 1989; 39: 686 - 692. imaging with morphology. Ultrasound Med 1987; 6: 363 - 366.
16. Gritzmann N, Grasi MCH, Helmer M et al. Invasion of the 37. Bluth El, Kay D, Merritt CRB et al. Sonographic characterization
carotid artery and jugular vein by lymph node metastases: of carotid plaque: detection of hemorrhage. AJR 1986; 146: 1061
detection with sonography. AJR 1990; 154: 411 - 414. - 1065.
17. Cooding GAW, Langman AW, Dillon WP et al. Malignant 38. Stahl JA, Middleton WD. Pseudoulceration of the carotid artery -
carotid artery invasion: sonographic detection. Radiolog - 1989; . J Ultrasound Med 1992: 11: 355 - 358.
171: 435 - 438. 39. F'urst H, Harti WH, Jansen I et al. Color - flow Doppler
18. Steinke W, Hennerici M, Aulich A. Doppler color flow imaging soiiography in the identification of ulcerative plaques in patients
of carotid body tumors. Stroke 1989: 20: 1574 - 1577. with high grade carotid artery stenosis. AJNR 1992; 13: 1581 -
19. Tihansky DP, Porter PS. Pulsed Doppler - ultrasonic diagnosis of 1587.
carotid body tumor. NY State J Med 1989: 89: 580 - 582. 40. Grant EG. Duplex sonography of the cerebrovascular system. In:
Grant EG, White EM, eds. Duplex Sonography. New - York:
Ky thuat sieu am ong mach canh
Springer - Verlag: 1988: 7 - 68.
20. Grant EG, Wong W, Tessler F et al. Ccrebrovascular ultrasound
41. Comerota AJ, Granley JJ, Cook SE. Real - time B - mode carotid
imaging. Radio! Clin North Am 1988; 26: 1111 - 1130.
imaging in diagnosis of cerebrovascular disease. Surgery 1981:
Ly giai sieu am ong mach canh 89: 718 - 729.
21. Polak JE, O'Leary DH, Kronmal RA et al. Sonographic 42. Zwiebel WJ, Austin CW, Sackett JF et al. Correlation of high -
evaluation of carotid artery atherosclerosis in the elderly: resolution, B - mode and continuous - wave Doppler sonography
relationship of disease severity to stroke and transient ischemic with arteriography in the diagnosis of carotid stenosis. Radiology
attack. Radiology - 1993; 188: 363 - 370. - 1983; 149: 523 - 532.
22. Veller MG, Eisher CM, Nicolaides AN et al. Measurement of the 43. Jacobs NM, Grant EG, Schellinger D et al. Duplex carotid
ultrasonic intima - media complex thickness in normal subjects. sonography: criteria for stenosis, accuracy, and pitfalls. Radiology
Vase Surg 1993; 17: 719 - 725. 19S5 - A54: 385 - 391.
23. Bort ML, Mulder PGH, Hofman A et al. Reproducibility of 44. Zw - icbel WJ. Spectrum analysis in carotid sonography.
carotid vessel wall thickness measurements. The Rotterdam Ultrasound Med Biol 1987; 13: 623 - 636.
Study. Clin Epidemiol 1994; 47(8): 921 - 930. 45. Taylor KJW, Holland S. Doppler ultrasound: Pt I. Basic
24. O'Leary DH, Polak JF. High - resolution carotid sonography: principles, instrumentation, and pitfalls. Radiology - 1990: 174:
past, present, and future. AJR 1989; 153: 699 - 704. 297 - 307.
25. Bluth El, Stavros AT, Marich KW et al. Carotid duplex 46. Carroll BA, von Ramm OT. Fundamentals of current Doppler
sonography: a multicenter recommendation for standardized technology. Ultrasound Q 1988; 6: 275 - 298.
imaging and Doppler criteria. RadioOraphics 1988; 8: 487 - 506. 47. Kassam M, Johnston KW, Cobbold RSC. Quantitative estimation
26. Langsfield M, Gray - Weale AC, Lusby RJ. The role of plaque of spectral broadening for the diagnosis of carotid arterial
morphology and diameter reduction in the development of new disease: method and in vitro results. Ultrasound Med fito/1985; ll:
symptoms in asymptomatic carotid arteries. Vase Surg 1989, 9: 425 - 433.
548 - 557.
48. Douville Y, Johnston KW, Kassam M. Determination of the 70. Zbornikova V, Lassvik C. Duplex scanning in presumably normal
hemodynamic factors which influence the carotid Doppler persons of different ages. Ultrasound Med Biol 1986, 12: 371 -
spectral broadening. Ultrasound Med Biol 1985; 11: 417 - 423. 378.
49. Garth KE, Carroll BA, Sommer FG et al. Duplex ultrasound 71. O' Boyle MK, Vibhaker N1, Chung J et al. Duplex sonography of
scanning of the carotid arteries with velocity spectrum analysis. the carotid arteries in patients with isolated aortic stenosis:
Radiology 1983; 147: 823 - 827. imaging findings and relation to severity of stenosis. AJR 1996:
50. Phillips DJ, Greene FM, Langlois Y et al. Flow velocity patterns 166: 197 - 202.
in the carotid bifurcations of young, presumed normal subjects. 72. Haves AC, Johnston W, Baker WH et al. The effect of
Ultrasound Med Biol 1983; 9: 39 - 49. contralateral disease on carotid Doppler frequency. Surge^1988:
51. Lichtman JB, Kibble MB. Detection of intracranial arteriovenous 103: 19 - 23.
malformation by Doppler ultrasound of the extracranial carotid 73. Blackshear WM, Phillips DJ, Chikos PM et al. Carotid artery
circulation. J Ultrasound Med 1987; 6: 609 - 612. velocity patterns in normal and stenotic vessels. Stroke 1980; 11:
52. Robinson ML, Sacks D, Perlmutter GS et al. Diagnostic criteria 67 - 71.
for carotid duplex sonography. AJR 1988; 151: 1045 - 1049. 74. Berman SS, Devine JJ, Erdoes LS et al. Distinguishing carotid
53. Kohler TR, Langlois Y, Roederer GO et al. Variability in artery pseudo - occlusion with color - flow Doppler. Stroke 1995:
measurement of specific parameters for carotid duplex 26: 434 - 438.
examination. Ultrasound Med Biol 1987; 13: 637 - 642. 75. Gortter M, Niethammer R, Widder B. Differentiating subtotal
54. Friedman SG, Hainline B. Feinberg AW et al. Use of diastolic carotid artery stenoses from occlusions by colour - coded duplex
velocity ratios to predict significant carotid artery stenosis. 5fr - sonographv. J Neurol 1994: 241: 301 - 305.
oA: e'1988; 19: oiO - 912. 76. Kliewer MA, Freed KS, Hertzberg BS et al. Temporal artery tap:
55. Hunink MGM, Polak JF, Barlan MM et al. Detection and usefulness and limitations in carotid sonography. In press.
quantification of carotid artery stenosis: efficacy of various Radiology.
Doppler velocity parameters. AJR 1993; 160: 619 - 625. 77. Bebrv AJ, Hines GE. Total occlusion of the common carotid
56. Moneta GL, Edwards JM, Chitwood RW. Correlation of North artery with a patent internal carotid artery; report of a case. J
American Symptomatic Carotid Endarterectomy Trial (NASCET) F^c'5urgl989; 10: 469 - 470.
angiographic definition of 70 to 99 internal carotid artery stenosis 78. Blackshear WM, Phillips DJ, Bodily KG et al. Ultrasonic
with duplex scanning. Vase Surg 1993; 17: 152 - 159. demonstration of external and internal carotid patency with
57. F aught WE, Mattos MA, van Bemmelen et al. Color - flow common carotid occlusion: a preliminary report. Stroke 1980: 11:
duplex scanning of carotid arteries: new velocity criteria based on 249 - 252.
receiver operator characteristic analysis for threshold stenoses
79. Executive Committee for the Asymptomatic Carotid
used in the symptomatic and asymptomatic carotid trials. Vase
Atherosclerosis Study. Endarterectomy for asymptomatic carotid
Surg 1994; 19: 818 - 828.
artery stenosis. JAMA 1995: 273: 1421 - 1428.
58. Sumner DS. Use of color - flow imaging technique in carotid
80. Alexandrov AV, Bladin CF, Maggisano R et al. Measuring
artery disease. Surg din North Am 1990; 70: 201 - 211.
carotid stenosistime for a reappraisal. Stroke 1993: 24(9): 1292
59. Middleton WD, Erickson S, Melson GL. Perivascular color - 1296.
artifact: pathologic significance and appearance on color Doppler
81. Polak JF, Kalina P, Donaldson MC el al. Carotid endarterectomv:
ultrasound images. Radiology - 1989: 171: 647 - 652.
preoperative evaluation of candidates with combined Doppler
60. Polak JF, Dobkin OR, O'Leary DH et al. Internal carotid artery sonography and MR angiography. Radiolog} - 1993: 186: 333 -
stenosis: accuracy and reproducibility of color - Doppler - 338.
assisted duplex imaging. Radiology 1989: 173: 793 - 798.
82. Nicholas GG, Osborne MA, Jaffee JW et al. Carotid artery
61. Erickson SJ, Mewissen MW, Foley WD et al. Stenosis of the stenosis: preoperative noninvasive evaluation in a community
internal carotid artery: assessment using color Doppler imaging hospital. J Vase Surg 1995; 22: 9 - 16.
compared with angiographv. AJR 1989; 152: 1299 - 1305.
83. Mattos MA, Hodgson KJ, Eaught WE et al. Carotid end -
62. Middleton WD, Foley WD. Lawson TL. Flow reversal in the arterectomy without angiography: is color - flow - duplex
normal carotid bifurcation: color Doppler flow^ imaging anaysis. scanning sufficient? Surgery 1994; 116: 776 - 783.
Radiology - 1988: 167: 207 - 210.
63. Zierler RE, Phillips DJ, Beach KW et al. Noninvasive assessment
84. Cartier R. Cartier P, Fontaine A. Carotid endarterectomy without
angiography. The reliability of Doppler ultrasonography and
of normal carotid bifurcation hemodynamics with color - flow
duplex scanning in preoperative assessment. CJS 1993; 36(5):
ultrasound imaging. Ultrasound Med Biol 1987; 13: 471 - 476.
411 - 415.
64. Erickson SJ, Middleton WD, Mewissen MW et al. Color Doppler
85. Fontenelle LJ, Simper SC, Hanson TL. Carotid duplex scan
evaluation of arterial stenoses and occlusions involving the neck
versus angiographv in evaluation of carotid artery disease. Am
and thoracic inlet. RadioGraphics 1989: 9: 389 - 406.
1994; 60(ll): 864 - 868.
65. Middleton WD, Foley WD, Lawson TL. Color - flow Doppler
imaging of carotid artery abnormalities. AJR 1988: 150: 419 - Ly giai sieu am ong mach canh
425. 86. Furie DM Tien RD. Eibromuscular dysplasia of arteries of the
66. Merritt CRB. Doppler color flow imaging. J Clin Ultrasound head and neck: imaging findings. A. JR 1994; 162: 1205 - 1209.
1987; 15: 591 - 597. 87. Kliewer MA, Carroll BA. Ultrasound case of the day.
67. Branas CC, Weingarten MS, Gzeredarczuk M et al. Examination RadioGraphics 1991 ; 11: 504 - 505.
of carotid arteries with quantitative color Doppler flow imaging. J 88. Maeda H, Handa N, Matsumoto M et al. Carotid lesions detected
Ultrasound Med WW: 121 - \27. by B - rnode ultrasonography in Takayasu's arteritis: "macaroni
68. Griewing B, Driesner F, Kallwellis G et al. Cerebrovascular sign" as an indicator of the disease. Ultrasound MedBiol 1991;
disease assessed by color - flow and power Doppler 17(7): 695 - 701.
ultrasonography. Stroke 1996; 27: 95 - 100. 89. Gardner OJ, Gosink BB, Kallman CE. Internal carotid artery
69. Taylor DC, Strandness DE. Carotid artery duplex scanning. J Clin dissections: duplex ultrasound imaging. J Ultrasound Med 1991;
Ultrasound 1987; 15: 635 - 644. 10: 607 - 614.
90. Sturzenegger M. Spontaneous internal carotid artery dissection: 109. Garroll BA, Holder CA. Vertebral artery duplex souography
early diagnosis and management in 44 patients. Jneurol 1995; (abstract). J Ultrasound Med 1990: 9: S27 - 28.
242: 231 - 238. 110. deBray JM et al. Effect of subclavian syndrome on the basilar
91. Sturzenegger M. Mattle HP, Rivoir A et al. Ultrasound findings artery. Ada Neurol Scand 1994: 90: 174 - 178.
in carotid artery dissection: analysis of 43 patients. Neurology 111. Thomassen L. Aarii JA. Subclavian steal phenomenon. Acta
1995; 45: 691 - 698. Neurol Scand 1994; 90: 241 - 244.
92. Steinke W, Rautemberg W, Scjwartz A et al. Noninvasive 112. Courneya DL, Carroll BA. Vertebral artery pro - steal wave -
monitoring of internal carotid artery dissection. Stroke 1994; form: the "bunny" waveform. Presented at the 1995 Radiological
25(5): 998 - 1005. Society of North America.
Doppler xuyen so 113. Branchereau A, Magnon PE, Espinoza H et al. Subclavian artery
93. Lupetin AR, Davis DA, Beckman J et al. Transcranial Doppler stenosis: hemodynamic aspects and surgical outcome. J
sonography. Pt 1. Principles, technique and normal appearance. Cardiovasc Surg 1991; 32: 604 - 611.
RadioGraphics 1995; 15(1): 179 - 19 - 1. Tnh mach di on
94. Comerota AJ, Katz ML, Hosking JD et al. Is transcranial Doppler 114. Williams CE, Lamb GHR, Roberts D et al. Venous thrombosis in
a worthwhile addition to screening tests for cerebrovascular the neck: the role of real time ultrasound. Eur J Radiol 1989: 9:
disease / Vase Surg 1995: 21: 90 - 97. 32 - 36.
95. Rorick MB, Nichols FT, Adams RJ. Transcranial Doppler 115. Hubsch PJS, Stiglbauer RL, Schwaighofer BWAM et al. Internal
correlation with angiography in detection of intracranial stenosis. jugular and subclavian vein thrombosis caused by central venous
Stroke 1994; 25: 1931 - 1934. catheters: evaluation using Doppler blood flow imaging.
96. Lupetin AR, Davis DA, Beckman et al. Transcranial Doppler Ultrasound Med 1988: 7: 629 - 636.
sonography. Pt 2. Lvaluation of intracranial and extracranial 116. Gaitini D, Kaftori JK, Pery M et al. High - resolution real - time
abnormalities and procedural monitoring. RadioGraphics 1995; ultrasonography: diagnosis and follow - up of jugular and sub -
15: 193 - 209. clavian vein thrombosis. Ultrasound Med 1988: 7: 621 - 627.
97. Lin SU, Ryu SJ, Chu NS. Carotid Doppler and transcranial color 117. Albertyn LE, Alcock MK. Diagnosis of internal jugular vein
coded sonography in evaluation of carotid - cavernous sinus thrombosis. Radiology 1987; 162: 505 - 508.
fistulas. Ultrasound Med 1994, 13: 557 - 564. 118. Falk RL, Smith DF. Thrombosis of upper extremity thoracic inlet
98. Mast H, Mohr JP, Thompson JLP et al. Transcranial Doppler veins: diagnosis w4th duplex Doppler sonography. AJR 1987;
ultrasonography in cerebral arteriovenous malformation. Stroke 149: 677 - 682.
1995: 26: 1024 - 1027. 119. Weissleder R, Elizondo G, Stark DD. Sonographic diagnosis of
99. Gaunt ME, Martin PJ, Smith JL et al. Clinical relevance of subclavian and internal jugular vein thrombosis. J Ultrasound
intraoperative embolization detected by transcranial Doppler Med 1987; 6: 577 - 587.
sonography during carotid endarterectomy: a prospective study of 120. De W^itte BR, Lameris JS. Real - time ultrasound diagnosis of
100 patients. BrJSurg 1994; 81: 1435 - 1439. internal jugular vein thrombosis. J Clin Ultrasound 1986: 14: 712 -
ong mach ot song 717.
100. Bendick PJ, Glover JL. Hemodynamic evaluation of vertebral 121. Wing V, Scheible W. Sonography of jugular vein thrombosis.
arteries by duplex ultrasound. Surg din North Am 1990: 70: 235 - AJR 1983; 140: 333 - 336.
244. 122. Gribbin C, Raghavendra BN, Ginsburg HB. Ultrasound diagnosis
101. Lewis BD, James EM, Welch TJ. Current applications of duplex of jugular venous ectasia. NY State J Med 1989: 9: 532 - 533.
and color Doppler ultrasound imaging: carotid and peripheral 123. Hughes PL, Qureshi SA, Galloway RW. Jugular venous
vascular system. Mayo Clin Proc 1989: 64: 1147 - 1157. aneurysm in children. BrJRadiol 1988: 61: 1082 - 1084.
102. Visona A, Lusiani I. , Castellani V et al. The echo - Doppler 124. Jasinski RW, Rubin JM. Computed tomography and ultra -
(duplex) system for the detection of vertebral artery occlusive sonographic findings in jugular vein ectasia. J Ultrasound Med
disease: comparison with angiography. Ultrasound Med 1986: 5: 1984: 3: 417 - 420.
247 - 250. 125. Stevens RK, Fried AM, Hood TR. Ultrasonic diagnosis of jugular
103. Davis PC, Nilsen B, Braun IF et al. A prospective comparison of venous aneurysm. J Clin Ultrasound 1982: 10: 85 - 87.
duplex sonography vs angiography of the vertebral arteries. A. 126. Lee W, Leduc L, Cotton DB. Ultrasonographic guidance for
INR 1986; 7: 1059 - 1064. central venous access during pregnancy. Am J Obstet Gynecol
104. Bluth El, Merritt CRB, Sullivan MA et al. Usefulness of duplex 1989: 161: 1012 - 1013.
ultrasound in evaluating vertebral arteries. Ultrasound Med 1989; 127. Bond DM. Nolan R. Real - time ultrasound imaging aids jugular
8: 229 - 235. venipuncture. Anesth Analg 1989; 68: 700 - 701.
105. Walker DW, Acker JD, Cole CA. Subclavian steal syndrome 128. Machi J, Takeda J, Kakegawa T. Safe jugular and subclavian
detected with duplex pulsed Doppler sonography. AJNR 1982; 3: venipuncture under ultrasonographic guidance. Am J Surg 1987;
615 - 618. 153: 321 - 323.
106. Elias DA, Weinberg PE. Angiography of the posterior fossa. In: 129. Dresser LP, McKiimey WM. Anatomic and pathophysiologic
Taveras JM, Ferrucci JT, eds. Radiology: Diagnosis - Imaging - studies of the human internal jugular valve. Am J Surg 1987: 154:
Interuention. Philadelphia: JB Lippincott Co; 1989; 3: 6 - 7. 220 - 224.
107. Bendick PJ, Jackson VP. Evaluation of the vertebral arteries with 130. Patel S, Brennan J. Diagnosis of internal jugular vein thrombosis
duplex sonography. Vase Surg 1986: 3: 523 - 530. by computed tomography. J Comput Assist Tomogr 1981: 5: 197 -
108. Ackerstaff RGA, Grosveld WJHM, Eikelboom BC et al. 200.
Ultrasonic duplex scanning of the prevertebral segment of the 131. Braun IF, Hoffman JC, Maiko JA et al. Jugular venous
vertebral artery in patients with cerebral atherosclerosis. Eur J thrombosis: magnetic resonance imaging. Radiology 1985: 157:
Vase Surg 1988; 2: 387 - 393. 357 - 360.
C H N G 2 9
Cac ong mach ngoai bien

Joseph F. Polak, M.D.
D A N B A I Sieu am anh gia de dang cac ong mach chi

tren va chi di. Khao sat thng khong co cac
THIET B gii han ve ky thuat va tng tac song am nh khi
Hnh anh thang xam thi gian thc khao sat mach mau vung bung hoac ngc. ong
Sieu am Doppler thi co u cac ca so u ln e co the at au do
CAC KIEU DONG ONG MACH TREN tren mach mau can khao sat ma khong b can tr
DOPPLER do cac xng. Thng dung au do tan so cao vi
Cac ong mach bnh thng tan so tren 5 MHz v cac mach mau thng nam
Cac ong mach b hep
nong gan da vi chieu sau toi a 6 cm.
Cac ro ong-tnh mach
Sieu am thang xam rat tot trong anh gia cac
Cac u mach mau-gia phnh ong mach
mang x va hoac xac nh cac khoi u ben ngoai
BENH LY ONG MACH NGOAI BIEN
mach mau. Tuy nhien, loai sieu am nay gii han
Tan suat va tam quan trong cua lam sang
Chi di trong anh gia hep (Hnh 29-1). Sieu am Doppler
Giai phau bnh thng va cac kieu dong mau va sieu am pho la cong cu chan oan tot trong
chay Doppler xac nh mang x va, chan oan phan biet hep va
Phnh machtieu chuan chan oan tac va anh gia ban chat cac khoi u quanh mach
Phnh machtnh chnh xac trong chan (nh phan biet khoi mau tu vi gia phnh). Sieu
oan am Doppler mau xac nh kieu dong chay. Khi so
Hep va tactieu chuan chan oan sanh vi sieu am duplex, sieu am Doppler mau co
Hep va tactnh chnh xac trong chan the khao sat mach mau dien tch ln hn va dai
oan hn trong thi gian ngan hn. Ngoai tiet kiem thi
Chi tren gian khao sat, sieu am Doppler mau lam tang tnh
Giai phau bnh thng va cac kieu dong chnh xac cua chan oan.1,2 Sieu am Doppler nang
chay Doppler lng co hoac khong dung chat tang am (tng
Sinh ly benh va tnh chnh xac trong phan) co the gop phan vao tnh chnh xac cua chan
chan oan oan cua sieu am. Do o sieu am that s ngay
CAC MANH GHEP MACH MAU( GRAFTS)
cang c ng dung trong anh gia cac benh nhan
Cac bien chng cua cau noi mach mau
b nghi ng hoac co benh ly ong mach.
loai tong hp
So sanh vi chup quang mach mau
Gia phnh hoac tu mau
(angiography), sieu am co nhng u iem cua ky
Hep va tac
thuat khao sat khong xam lan, re va thch hp cho
Cac manh ghep mach mau t than
Hep khao sat theo doi. Chup ong mach ky kieu cat
Ro ong-tnh mach lp CTA (Computed Tomographic Angiography)
Ro manh noi trong loc mau co the so sanh vi sieu am nhng rat at tien,
Bien chng cua cac thu thuat xam lan thng lien quan en phong xa va phai chch tnh
Ro ong-tnh mach mach chat can quang. CTA co o phan giai thap
Gia phnh hn sieu am va khong the cho hnh anh nhng
922 SIEU AM PHAN MEM, ONG MACH CANH VA CAC MACH MAU NGOAI BIEN
Hnh 29-1. So sanh khao sat thang xam va doppler cua hep ong mach A. Hnh
thang xam cua ong mach ui nong (S) khong thay ton thng quan trong. B. Sieu am Doppler
cho thay gia tang van toc ti 5 m/giay, tng ng hep ro. C. Khao sat Doppler oan trc hep
cho thay dang song nh tam thu cong b ham lai (dampened) va khang lc cao. D. Hnh mau
cho thay v tr hep co hnh hep cua long mach mau va hien tng vt ngng tai v tr hep nhat.
Tnh hieu mau bat thng cua dong chay trai rong t nhat 1 cm ngay sau hep
mach mau ma co ng knh long nho hn 5 mm. t MRI co the dung trong cac benh ly ngoai mach.
Chup mach mau bang cong hng t MRA Noi chung, CTA va MRA hieu qua hn sieu am
(Magnetic Resonance Angiography) co the xac nhng mac tien hn.
nh cac hep nho va tac nghen. Chup cong hng
Cac ong mach ngoai bien 923
THIET B chuyen dch trung bnh tao bi cac cau truc di

chuyen. Hau het cac nha san xuat dung tan so
Sieu am thang xam thap hn cho sieu am mau dong chay so vi sieu
Cac ong mach ngoai bien co kch thc thay oi 1 am trang en. ieu nay khac phuc c hien
en 6 mm. Khao sat hnh anh long ong mach vi tng vt ngng cua dong chay, hien tng nay
au do o phan giai cao, thng tren 3,5 MHz cho thng xay ra khi toc o khung hnh (frame) thap.
phep xac nh mang x va. Thng dung au do Sieu am Doppler nang lng la dang khac
t 5 en 10 MHz. Tuy nhien au do 5 MHz thng cua sieu am Doppler mau, chu yeu da tren s di
cho o phan giai tng oi tot va at o sau khao chuyen te bao mau. u iem cua sieu am Doppler
sat can thiet. Neu khao sat ong mach nho hn, co nang lng la khong co hien tng vt ngng,
the dung au do 7 MHz. au do 10 MHz dung tn hieu thu c t phu thuoc vao goc Doppler va
khao sat cac cau truc nam nong nh cac mang co the khao sat cac te bao mau di chuyen cham.
ghep noi va ong mach nho nh ong mach tru va Mot khuyet iem la khong xac nh c hng
ong mach quay. cua dong chay.
au do phang (linear phased array) ly tng
cho khao sat cac ong mach chi. au do co u CAC KIEU DONG CHAY ONG MACH
chieu dai cho phep khao sat tng oan dai bang TREN DOPPLER
cach trt doc theo ong mach khi khao sat. au
do cong vi chan do nho hoac au do sector hu Cac ong mach bnh thng
dung khi khao sat mach mau sau nh cac ong Kieu Doppler bnh thng cua ong mach chi la
mach chau va cac oan cua ong mach di on. dang pho (song) ch so khang lc cao, phan anh
tnh trang co that cac mach mau nho pha xa (Hnh
Sieu am Doppler 29-2). Kieu dong chay nay hoan toan ngc vi
Cac au do quet bo am bang ien t ang thay the dong chay khang lc thap ong mach canh chung
loai quet bang c hoc trong sieu am thang xam va va canh trong. Kieu dong chay ong mach chi
sieu am Doppler. Sieu am duplex, la sieu am ien hnh la song dang ba pha (triphasic)( Bang
thang xam ket hp co song pho, rat can thiet trong 29-1). Song nay bao gom phan dong chay hng
khao sat ong mach ngoai bien va manh noi ong ti manh trong tam thu, theo sau la dong chay
mach.3 Viec x ly can than hnh anh thang xam ngc nho trong au tam trng. Tiep theo la
thi gian thc la can thiet e at chnh xac cong dong chay hng ti vi bien o thap trong thi
thu tn hieu Doppler va o chnh xac toc o toi a gian con lai cua tam trng. Phan tam trng cua
dong chay tai cac ong mach nho. Tan so Doppler dong chay rat thay oi, co the mat khi co manh do
dung t 3 en 10 MHz, co khuynh hng thap hn lanh hoac keo dai khi nong hoac sau tap the duc.
tan so cho sieu am thang xam. Thng dung tan
so 5MHz nhat v cho phep khao sat dong chay Cac ong mach hep
cham va tranh hien tng vt ngng mau Kieu khang lc cao bnh thng tr thanh khang
(aliasing) ma thng xay ra vi dong chay nhanh lc thap khi co benh ly ong mach ro rang nam
nh trong hep hoac ro ong-tnh mach. gan so vi v tr khao sat. Kieu khang lc thap nay
Sieu am Doppler mau dong chay ngay nay giong kieu pho trong ong mach canh trong, phan
rat can thiet cho sieu am ong mach ngoai bien. anh tai lap tuan hoan bang he va mat trng lc
Hnh anh dong chay tren hnh thang xam cho phep ong mach bnh thng e ap ng tnh trang thieu
khao sat nhanh chong kieu dong chay trong mot mau. Kieu nay thng thay oan xa v tr tac
oan dai cua ong mach ngoai bien va cac cau noi ong mach nhng cung co the thay oan xa cho
mach mau.4 Noi chung, hieu qua cua sieu am hep nang.
mach mau ngoai bien da tren sieu am Doppler S tang van toc khu tru xay ra tai v tr hep.
mau e nhanh chong xac nh vung chay roi Khao sat s tang nay bang s chenh lech trong t le
(disturbances) va da tren sieu am duplex vi pho tan so Doppler vi ng knh ngang long mach tai
Doppler xac nh cac loai bat thng cua dong cho hep.6-8 Sieu am pho cho thay tang van toc
chay.1,5 Sieu am Doppler mau bieu dien tan so nh tam thu hoac giam o bao hoa mau hoac gay
924 SIEU AM PHAN MEM, ONG MACH CANH VA CAC MACH MAU NGOAI BIEN
lech mau trung bnh
Hnh 29-2. Giai phau ong mach chan bnh thng va dang song Doppler. Dang pho
Doppler bnh thng cua dong chay tai cac ong mach chi di co dang ba pha: (1) dong chay hng ti
trong tam thu, (2) giai oan ngan cua dong chay ngc trong au tam thu, va (3) mot phan thay oi cua
dong chay toc o thap trong thi gian con lai tam trng. Tn hieu Doppler ong mach dung e o van toc
dong chay khao sat vi au do at song song mach mau va goc khao sat gia hng chum am va hng
dong chay nho hn hoac bang 60 o.
hien tng vt ngng mau (Hnh 29-1). S di trong tnh mach thng b ong mach hoa. Tia
chuyen mau pha xa cho hep tr nen roi (mat to mau vi van toc chay cao co the tao hnh anh
chc cua dong chay bnh thng) va bieu hien thay nhieu Doppler do cau truc xung quanh mach di
oi ro trong hng chay va van toc va anh hng ong.9 Mot nguyen nhan thong thng cua chan
nay that s xay ra tren mot hoac vai centimet. Co oan dng tnh gia ro ong tnh mach la khoi mau
the khao sat vung chay xoay tren sieu am duplex tu gay chen ep len tnh mach tao s gia tang van
bang dau hieu xoa ca so (spectral window toc du khong co song ap trong tnh mach.
broadening) va s thay oi ro tren sieu am mau.
Khoi u mach mau- gia phnh mach
Ro ong-tnh mach Sieu am Doppler mau va sieu am pho giup chan
Ro ong-tnh mach co the do bam sinh hoac loi oan phan biet cac khoi u quanh mach mau. S
cua ieu tr. Cac ro bam sinh la s thong thng hien dien cua dong chay trong khoi u dang nang
bat thng gia ong mach va tnh mach b gian to. nam sat ong mach cho phep ngh ti gia phnh
Cac ro thng thay ro tren lam sang v nam nong ong mach. Gia phnh ong mach oi khi co the
gan mat da chi. Cac ro nay thng thay cac tnh xay ra sau thu thuat at catheter hoac sau chan
mach ln thong vi mot hoac nhieu nhanh ong thng xuyen thau. Dang chay xoay ien hnh
mach. Khi cac ro ong-tnh mach to ra, cac tnh hoac dau hieu yin-yang thay trong khoi
mach co the khong co gian va thng ghi nhan phnh.10,11 Vi gia phnh, co co khau knh nho hien
tang toc o dong chay trong tnh mach do ro. len di dang mot ng noi thong thng gia
Ro do loi ieu tr co the xay ra sau cac thu ong mach va khoi phnh.12 Dau hieu To and
thuat at catheter ong mach hoac tnh mach hoac Fro c xac nh tren sieu am duplex (Hnh 29-
do chan thng xuyen thau. S thong thng co 4). Thanh phan To tao bi dong chay trong tam
the thay tia mau va gian tnh mach gian to bat thu do s gian to cua khoi phnh (Hnh 29-5).
thng so vi oi ben (Hnh 29-3). Dong chay Thng dung thang van toc cao (pulse repetition
BANG 29-1
CAC KIEU DONG CHAY ONG MACH TREN DOPPLER
Dang dong chay S o Tng quan
Tn hieu ba pha Cac tn hieu bnh thng luc ngh
vi dong chay ngc au tam
trng cho thay ging ong mach
pha xa bnh thng va ti mau
ay u
Tn hieu hai pha, khong co dong Co that ong mach hoac tac ong
chay tam trng mach cap pha xa cho khao sat
Dong chay cham mot pha vi Gian ong mach pha xa cho tac
nh tam thu keo dai ( tardus hoac hep nang
parvus); khong co dong chay
ngc, dong chay ti lien tuc
suot chu ky tim
Dong chay xoay lien tuc van toc Ro ong tnh mach
cao mot pha
Dong chay ti tam thu va chay Dong chay ngc tam trng co
ngc tam trng, ien hnh cua gia phnh do ban chat trng
kieu ti-lui To and Fro lc cua gia phnh
Hnh 29-3. Kieu dong chay ro ong-tnh mach. A, Hnh anh mau cua dong chay nay cho thay tia
van toc cao t ong mach ui sau, A, vao trong tnh mach ui chung b gian, V. B, Tn hieu dang ong mach
khang lc thap tai cho thong gia ong va tnh mach la ien hnh cua ro ong-tnh mach.
Hnh 29-4. Gia phnh mach ong mach ui. A, Hnh anh Doppler mau cat doc ong mach ui chung ben
phai vao ngay th nhat sau chup quang ong mach cho thay khoi bau duc (mui ten) pha trc ong mach. Tai
thi gian thc, nhan dien ra mau chay cuon xoay va tai v tr ro thay tia mau xanh do vt ngng mau t mat
trc cua ong mach. B, Hnh anh cat ngang Doppler tai co cua gia phnh mach cua mot benh nhan khac cho
thay dang pho To and Fro.
Hnh 29-5. Dang dong chay cua gia phnh mach. Nhan dien chuyen ong cuon xoay
cua dong chay, cung nh mot kenh thong lien gia ong mach va khoi tu quanh mach. Trong th
tam thu do ap lc mau trong ong mach cao hn so vi trong khoi tu nen mau i vao gia phnh
mach (To). Trong th tam trng, mau thoat ra (fro) do ap lc trong mo xung quanh khoi tu
dch cao hn ap lc tam trng.
Frequency = PRF) e khao sat v dong chay trong hnh dang ien hnh va v tr ben trong gii han cua
cho thong noi co van toc cao. Thanh phan Fro thanh ong mach. Mac du phnh mach dang thoi
thay trong tam trng do mau chay ngc vao (fusiform) nhan biet theo kieu nay nhng neu
trong ong mach. Thanh phan Fro thng u the phnh mach thuoc dang tui (saccular),15 co the gap
hn neu gia phnh ong mach gian to ro ret va co kho khan phan biet vi gia phnh mach.
s thay oi ro ap lc gia tam thu va tam trng.
Du thng xay ra n oc, phnh ong mach co the BENH LY ONG MACH NGOAI BIEN
co dang nhieu khoang thong thng nhau. Gia
phnh cung co the xay ra vi manh noi mach mau Tan suat va lam sang
nhan tao. ng thong thng trong trng hp Benh ly ong mach ngoai bien giong nh cac benh
nay thng rong hn so vi gia phnh do thong ly mach vanh hoac benh ong mach canh. S
mach bang catheter. tng ong cua ba qua trnh benh ly kha ro v ca
Hach bach huyet tang san la mot dang khoi u ba b anh hng bi tnh trang x va. Tuy nhien
quanh mach co the lam vi gia phnh do tn hieu bieu hien va dien tien lam sang cua ba benh ly
ong mach va tnh mach lan toa vung ron hach.13,14 nay khac nhau. Benh ly ong mach vanh va ong
Tuy nhien, hach nay khong co ng thong thng mach canh co the bieu hien benh canh tram trong
vi ong mach ke can hoac khong co dang To nh nhoi mau c tim hoac tai bien mach mau nao.
and Fro. De nhan biet phnh ong mach bang Nhieu benh nhan chu ng benh ly ong mach
ngoai bien trong nhieu nam trc khi ieu tr.17 nong hoac ong mach khoeo. ong mach ui
ieu nay chng to a coo1 tuan hoan bang he bnh nong tiep tuc chay xuong mat trong ui o sau 4
thng phat trien u duy tr ti mau cho cac chi en 8 cm ti ong c khep. ong mach nay i qua
cua benh nhan gia. S can bang gia cung va cau ong c khep va khi ra khoi khe c khep tr thanh
c gi vung mien la benh nhan khong tap the ong mach khoeo. ong mach khoeo i pha sau
duc hoac di chuyen qua o. Nhieu benh nhan co au goi va cho cac nhanh nho va tan cung bang hai
the tiep tuc tnh trang nay cho nhieu nam, giam nhanh ln: ong mach chay trc va than chay-
mc o hoat ong khi benh tien trien. i khap mac. ong mach chay trc chay xuyen qua
khenh thng la trieu chng benh nhan tre co mang gian cot vao khoang trc cua cang chan.
hoat ong hang ngay mc o cao. ong mach nay cuoi cung thanh ong mach lng
Mot ly do khac khien benh nhan tm ti ieu ban chan sau khi i qua mat ca. Than chay-mac
tr la nhng thay oi man cua tnh trang suy ong cho hai nhanh: ong mach chay sau va ong
mach nh vet thng lau lanh. Hien tng thuyen mach mac, cung cap mau cho c cang chan. ong
tac cap co nguon goc t sang thng ong mach mach chay sau thng nam nong hn ong mach
oan gan nh mang x va, huyet khoi trong phnh mac va thng co the khao sat ong mach nay doc
ong mach khoeo co the gay ton thng da lan toa ti sau trong xng got.
va co the oan chi neu khong can thiep ieu tr. Kieu dong chay trong tat ca cac nhanh nay co
Phau thuat lam cau noi ong mach rong rai a dang ba pha (Hnh 29-2). Co s tang toc au tam
cai thien benh ly ong mach ngoai bien. S tai tao thu theo sau la giai oan ngan cua dong chay
thong thng tot cua hai ky thuat lam cau noi va ngc bien o thap trc khi tr lai dong chay tam
tao hnh ong mach a cu benh nhan trc ay thu hng ti vi toc o cham. Kieu dong chay
phai oan chi khong con trieu chng. Cac nguyen nay co the ap manh hn trong ong mach ui sau.
nhan benh ly tim mach thng la nguyen nhan chet Van toc nh tam thu thay oi doc theo ong mach,
trong benh nhan co tnh trang x va mach mau thng khoang 100 cm/giay ong mach ui
tang dan. chung va khoang 70 cm/giay ong mach khoeo.
Sieu am pho thng dung nh la phng tien ong mach chay-mac co van toc khoang 40 en 50
au tien khong xam lan anh gia roi loan chc cm/giay. Phan ng oi vi tap the duc hoac thieu
nang cac cau noi chi di. Va cung ngay cang mau thoang qua la mat dang chay ba pha va co
c dung theo doi anh gia thanh cong cua phau dang mot pha (dong chay ch hng ti) vi mat
thuat tao hnh ong mach. Hnh anh Doppler mau thi ky ngan cua dong chay ngc va dong chay
ong mach chi thc te cho phep xac nh s lan ti u the trong tam trng (Hnh 29-6). Van toc
rong va ban chat cua cac sang thng ong mach. nh tam thu giam chi benh nhan co benh ly
Sieu am pho co the xac nh sang thng ong thieu mau ong mach; va van toc gia tang trong
mach nhng se mat nhieu thi gian va cong sc. benh nhan khoe manh sau tap the duc.
Ton khoang 30 en 60 phut e ve c s o cay Phnh ong machtieu chuan chan oan.
ong mach moi chi neu dung sieu am pho.18 Sieu Phnh ong mach hnh thanh do yeu thanh ong
am Doppler mau ton khoang 10 en 20 phut.1 mach. Cho phnh to hoac cho ln khu tru hn 20%
cua ng knh tao thanh phnh ong mach. Cho
Chi di phnh khu tru thng xay ra ong mach khoeo
Giai phau bnh thng va cac kieu dong hoac oan xa cua ong mach ui nong. Chung
chay tren Doppler. Cac ong mach sau cua chi thng xay ra hai ben va co the khong co trieu
di chay doc theo tnh mach. ong mach ui chng mot thi gian dai. Sieu am tr thanh tieu
chung bat au t day chang ben va chay khoang 4 chuan vang trong chan oan phnh.19,20 Sieu am co
en 6 cm va chia oi thanh ong mach ui nong the thay huyet khoi tao lap trong long phnh ong
va sau (Hnh 29-2). Nhanh ong mach ui sau mach ti thanh ong mach trong khi o chup ong
cung cap mau cho vung au xng ui va cac c mach cho thay long ong mach bnh thng (Hnh
sau vung ui. Trong benh ly ong mach ngoai 29-7). Sieu am co the anh gia theo doi cac phnh
bien, cac tuan hoan bang he thng tao lap gia nay nh phnh ong mach chu bung. Tuy nhien
ong mach ui sau vi phan di ong mach ui khong co mot tieu chuan nghiem tuc ve kch thc
Hnh 29-6. Dang Doppler song ong mach chi bat thng. Benh ong mach lam
thay oi dang song Doppler khao sat pha xa ton thng nh sau: tn hieu ong mach co dang
khang lc thap bnh thng thay trong ong mach canh trong hoac ong mach than vi dong
chay ti xay ra suot tam trng. Dang song Doppler khao sat oan trc hep nang hoac tac
cho thay mat dong chay tam trng
Phnh ong machtnh chnh xac chan

oan. Xac nh trc tiep benh hoc cua phnh ong
mach c chan oan bang sieu am cho thay ky
thuat nay co o nhay, o chuyen biet va tot hn
chup ong mach cang quang. Tnh chnh xac cua
ky thuat sieu am Doppler mau trong xac nh tnh
thong thng hoac tac cha c bao cao.
Hep va tac tieu chuan chan oan. Chan
oan benh ly ong mach ngoai bien thng da
Hnh 29-7. Phnh ong mach khoeo. Hnh anh cat doc vao s thay oi trong kieu dong chay tren sieu am
cua ho khoeo cho thay phnh ong mach d=3X4 cm( mui ten), Doppler pho Duplex (Hnh 29-8; Bang 29-2 va 29-
co cha huyet khoi. P ong mach khoeo
3).
Pha xa cua sang thng nhe cua ong mach,
dung e ch nh mo phnh ong mach. Theo kinh thi ky dong chay ngc trong tam thu giam va se
nghiem, cac phnh ong mach ngoai bien ln hn bien mat khi sang thong nang. Van toc tam
hoac bang 2cm thng phau thuat.21 Ch nh tuyet trng se tang t le theo tnh tram trong cua sang
oi phau thuat phnh ong mach khi co trieu chng thng du oi khi thay dang dong chay khang lc
do lap mach pha xa do huyet khoi ma khong can cao (Hnh 29-9). Vi nhng sang thng nang,
xem kch thc phnh.21 Sieu am Doppler mau rat dang dong chay chu yeu la dang dong chay hng
co ch trong xac nh tnh thong thng cua long ti vi van toc nh cuoi tam trng gan bang van
ben trong phnh co huyet khoi hoac trong khao sat toc nh tam thu. Mot ly do giai thch kieu dong
theo doi sau phau thuat. chay nay la s gian tien trien cua cac tieu ong
mach trong vung ging mach mau cua c vung xa
Hnh 29-8. Dang Doppler dong chay tng ng v tr hep nang. Trc hep, dong chay bnh
thng. Tai hep, van toc nh tam thu tang tng ng vi mc o hep. Cac thay oi cua phan tam trng
cua dang song Doppler khao sat tai hep phu thuoc vao tnh trang cua ong mach pha xa va mc o ton
thng va hnh hoc khong gian; dong chay tam trng co the tang ro hoac hau nh khong con. Xa cho
hep, van toc nh tam thu tr ve gia tr can bang hoac thap hn v tr trc hep. Neu hep tram trong, gian
mach ngoai bien tao s gia tang tng oi dong chay tam trng
BANG 29-2
HEP: CAC DAU HIEU VA MOI TNG QUAN
Dau hieu Tng quan
Van toc nh tam thu (PSV) > 200 cm/giay Hep toi thieu 50% khau knh
T le van toc nh tam thu so vi oan bnh thng ke Hep 50% khau knh hoac hn na
can trc hep bang hoac tren 2
Giam PSV vi dang song khang lc cao Khao sat Doppler ngay trc hep hoac tac
Tang van toc dong chay- dng tnh gia cua 1. Goc Doppler nhon.
hep 2. Mach gap
3. Khao sat ong mach bang he
Hnh 29-9. Hep nang. A, Hnh anh mau dong chay cho thay vt ngng mau tai ong mach ui mo
oan gia. Chup ong mach xac nh hep nang. B, Dang song Doppler khao sat tai ni vt ngng mau
cho thay s gia tang PSV ti 300 cm/giay nhng van con dong chay ngc trong tam trng
BANG 29-3
TAC ONG MACH: CAC DAU HIEU VA MOI TNG QUAN
Dau hieu Tng quan
Khong co tn hieu dong chay 1. Tac
2. Voi hoa
3. Tac gan hoan toan dng tnh gia
4. o nhay Doppler kem do cua tac
o sau hoac che o cai at
Phan am trong long ong mach Huyet khoi kem theo tac
Cac nhanh bang he ln trong khi khao sat mau Cho thay tac hoac hep nang oan xa
Dong chay ti lien tuc vi bien o thap suot trong V tr khao sat pha xa cho tac hoac hep nang
tam thu va tam trng
Tn hieu tam thu thap tai oan b tac 1. Tn hieu do nhp ap dan truyen trong oan tac
(am tnh gia) 2. Khao sat cac nhanh bang he song song oan b tac
do s phong thch cac hoat chat do hien tng bi hien tng gian mach, do o nen khao sat ch
thieu mau khu tru. Mot ly do khac la do s phat so van toc trong Doppler pho tai v tr nghi ng
trien cua he thong mach mau bang he nho lam hep. Kieu dong chay tang cham, bien o thap va
giam khang lc pha xa v tr tac. Kieu dong chay khang lc thap (tardus parvus) thng thay v tr
nay du thng thay nhng co the khong thay khi xa cua oan hep (Hnh 29-6; Hnh 29-10).
khao sat oan trc hep hoac tac. Tn hieu tai v V tr co van toc nh tam thu gap oi tng
tr trc hep ln thng co dang dong chay khang ng vi v tr hep hn 50% ng knh long
lc cao (Hnh 29-6). Neu khong co tuan hoan bang mach.22 Van toc tai v tr hep c chia cho van
he, dong chay ti co the ch thay trong thi ky tam toc trc cho hep (Hnh 29-8).
thu. V van toc nh tam thu khong b anh hng
Hnh 29-10. Dong chay pha xa cho tac. A, Hnh anh mau dong chay dung xac nh va anh gai ong
mach khoeo pha xa cho tac ong mach ui nong. Dong chay khong co chay ngc trong tam trng va van toc
trung bnh thap. B, Dang song Doppler tng ng tai ong mach khoeo cho thay bien o thap (parvus) vi
tang cham trong tam thu (tardus). Dang song nay ien hnh pha xa cho tac.
Hep va tac tnh chnh xac cua chan oan. gia he thong ong mach ui va khoeo. Thap hn
Kohler va cong s bao cao sieu am Doppler co o khi khao sat ong mach mac.28,29
nhay 82% va o chuyen biet 92% trong anh gia Sieu am Doppler mau dung cho hn 50% benh
oan hep cua ong mach ui-khoeo.18 Theo cac nhan co trieu chng ong mach ngoai bien trong
tac gia v tr khao sat thc hien doc theo ong ieu tr chon loc ma khong chup ong mach.30
mach ui va khoeo. Thng kch thc cac ong Sieu am Doppler mau cung dung trong ky thuat tai
mach dai khoang 30 en 40 cm, thng ton khoang tao mach mau ngoai bien e theo doi anh gia.31,33
1 en 2 gi, lau hn neu khao sat them ong mach S dung sieu am Doppler mau va Doppler
chau. duplex trong anh gia cac v tr ma co can thiep
Sieu am Doppler mau a tng cho thay giam di da nh tai tao mach hoac lay mang x va.
thi gian can thiet khi khao sat ong mach canh Mot bao cao cho rang o ong mach sau phau
nghi ng co hep khoang 40% khi so sanh vi ch thuat tao hnh mach mau tien oan s tai phat.34
dung sieu am Doppler pho.5 Tng t khi khao sat Cac nghien cu khac khong ong y vi quan iem
ong mach ui-khoeo bang sieu am Doppler mau. tren.35,36 Mot quan iem khac cho rang co the s
Tnh chnh xac cua chan oan hi tot hn sieu am dung Doppler duplex nh mot ky thuat theo doi lau
Doppler pho.2,23 Thi gian khao sat bang sieu am dai cho cac can thiep. V du, sau phau thuat lay
Doppler mau giam xuong khoang 30 phut.1 Nhieu mang x va co nguy c tac lai cao hn la benh
tac gia a bao cao tnh chnh xac cua sieu am mau nhan co trieu chng.37 Ly luan nay co the b gii
trong khao sat ong mach ngoai bien. Tnh chnh han v trieu chng cua benh nhan co the dan ti
xac gan 90% trong phan biet tac va khong tac ong can thiep tr lai.38 Theo doi hang loat phau thuat
mach. Tnh chnh xac trong chan oan hep hn tao hnh mach mau co the tien oan tai phat hep.39
85% ( Bang 29-4).1,24,25 Hau het cac so lieu thu
thap khi khao sat ong mach ui va khoeo, mot so Chi tren
Giai phau bnh thng va kieu dong chay
t khao sat ong mach chau, ong mach chay trc
va sau, va ong mach mac.18,23,26,27 anh gia cac Doppler. Cac ong mach chi tren i kem vi cac
ong mach cang chan khong chnh xac nh anh tnh mach; i kem cac tnh mach n oc tai v tr
co the gay hep ong mach di on do canh tay e

BANG 29-4
O NHAY CUA SIEU AM DOPPLER MAU SO
v tr gay ra trieu chng. Trieu chng thng xay
VI QUANG ONG MACH TRONG VIEC PHAT
ra khi tay t the dang qua o. Thng co s ket
HIEN CAC OAN ONG MACH HEP*
hp gia hoi chng nay vi lap (embolization)
So oan phat So oan
ong mach pha xa. S lan rong cua tac cap hoac
hien/so oan trong moi
man phai c ve dang cay s o e giup cho
b hep chi c
phau thuat tao cau noi trc khi cho benh nhan
Tac gia khao sat chup ong mach can quang. Cac trng hp tac
Cossman va cs.23 156/180 8 oan gan co the lien quan ti viem mach.
Polak va cs.33 22/29 7 Tac ong mach chi tren co the do la bien
Mulligan va cs.36
8/11 7 chng cua at thong tim; tac nay co the khao sat
Whelan va cs.25 130/141 7 bang sieu am mau va Doppler duplex. Co the
Tong cong 316/361=87.5% anh gia phan phu ne mo mem tai v tr boc lo
* Tng ng vi so lng cac oan c khao sat he thong ui- ong mach e phan biet khoi mau tu va gia phnh
khoeo moi ben. ong mach ui chung va ui sau c coi la tng
ong mach.
oan. ong mach ui nong ien hnh c chia thanh hai hoac ba
oan co o dai bang nhau trong khi ong mach khoeo cung c xem
la mot hoac hai oan. CAC GHEP NOI
di on va nach, i kem tnh mach kep tai v tr Cac bien chng cua ghep noi mach mau
canh tay va phan xa. oan gan ong mach di loai tong hp.
on co the khao sat bang cach hng au do Cac bien chng anh hng chc nang cac cau noi
xuong di tai ca so tren khp c-on. ong mach mau loai tong hp chi di a dang da
mach di on nam nong hn so vi tnh mach khi tren loai cau noi s dung va thi gian tnh t khi
at au do tai ho tren on. Gan cho noi 1/3 gia c ghep.40,41 Trong nam th nhat va th hai sau
va 1/3 gan cua xng on, can thiet dung au do mo, hep va tac cau noi thng th phat do loi ky
hng xuong. T v tr nay, thay ong mach di thuat hoac phat trien sang thng lp noi mac tai
on nam di tnh mach di on. V tr xuat phat v tr noi. Suy cau noi xay ra tre hn co the do
cua ong mach nach nam pha ngoai xng sn phat trien cac mang x va trong ong mach goc v
th nhat gan cho noi tnh mach au va tnh mach tr gan hoac xa cau noi. Bien chng tre: gia phnh
nach. ong mach nach khao sat doc ben trong mach xay ra 5 en 10 nam sau ghep va thng xay
tren oan gan canh tay va tiep noi ong mach ra tai v tr noi ui cua cau noi ong mach chu-
canh tay. Trong hau het trng hp, ong mach ong mach ui.5,42 Tnh trang nhiem trung co the
nay chay doc xuong ho khuyu trc ni bat au xay ra vao bat c luc nao va co the i kem vi s
chia ba nhanh: ong mach quay, ong mach tru va phat trien gia phnh mach tai cho noi.
nhanh lien xng. Co the khao sat ong mach Gia phnh so vi khoi mau tu. Du tnh chnh
quay va tru doc ti co tay, oi khi thay cac nhanh xac cua chan oan cua sieu am Doppler pho
nho xng ban tay. Dang dong chay ong mach duplex tren 95% trong chan oan gia phnh mach
canh tay giong dang dong chay chi di tc ba pha. mau hoac gia phnh quanh cau noi, khong co mot
Sinh ly benh va tnh chnh xac cua chan dang pho chuyen biet nao trong gia phnh c mo
oan. Hau het moi quan tam cua lam sang trong ta.43,44 Trong sieu am Doppler dong chay, co the
khao sat khong xam lan nhanh ong mach chi tren thay dang ien hnh chay cuon swirling trong
la trc tiep khao sat cho hep khu tru gay ra do hoi khoi u quanh mach mau.41 Dau hieu nay khong
chng ay co-ngc (thoracic outlet syndrome) do chuyen biet v cung co the thay trong phnh ong
tac ong mach goc do thuyen tac hoac lap mach, mach dang tui (saccular)(Hnh 29-5; Hnh 29-11
do gia phnh ong mach, do bien chng sau at en Hnh 29-13). Chan oan gia phnh da tren
catheter; va anh gia cau noi trong loc mau. khoi u mach mau nam ngoai long mach bnh
Co vai bao cao ve anh gia Doppler tren benh thng va dau ti va lui (to and fro sign) tren
nhan co hoi chng thoracic outlet. Hoi chng nay Doppler pho tai v tr thong thng gia khoi quanh
Hnh 29-11. Dang dong chay cua phnh ong

mach dang bau Fusiform . dang dong chay trong long
cua phnh se thay oi trong cac giai oan khac nhau cua Hnh 29-12. Phnh ong mach khoeo. Phnh ong
benh. Tren hnh nay, vi phnh nho thanh va mo lng nho mach vi lng nho huyet khoi dong theo thanh (mui ten).
huyet khoi, dong chay cuon eddies tao trong cuoi tam thu( Long mach thang do o khong co dong chay cuon trong tam
hnh tren). Trong tam trng, dong chay thng bnh thng thu
(hnh di).
Hnh 29-13. Dong chay cua phnh dang tui. Phnh nay co dong chay cuon trong cuoi tam thu
va phan ln tam trng. Dang nay tng ng vi dong chay cuon xoay (swirling). S khac biet gia
dang nay va gia phnh tai cho ghep noi nhan tao co the khong ro
mach va cau noi. Du chuyen biet, v tr thong e giam thieu hnh anh nhieu cua mau loai tr sai
thng nay oi khi kho xac nh vi Doppler pho so. Cai at thanh van toc mau (PRF) len cao co
va thng khong thay trong gia phnh tai cho noi the loai tr hnh anh nhieu trong khi o co the xac
(Hnh 29-4; Hnh 29-14). Sieu am Doppler mau nh c v tr thong noi cua gia phnh mach.
giup ch trong xac nh cho thong noi. Hep va tac. Hep cho noi gay gia tang ro van
Can can than trong chan oan phan biet khoi toc Doppler tai v tr noi hoac sau cho noi. Tuy
mau tu quanh mach co tnh ap vi mau chay nhien co mot khuynh hng bnh thng la dong
trong gia phnh ong mach. ieu chnh hnh anh chay xoay phat trien khi cau noi nho dan ti cho
Suy cau noi thng do ba nguyen nhan khac

nhau. Suy giai oan sm trong thang au sau phau
thuat va thng do loi ky thuat. Loi nay la do vet
khau noi kem, lo trong tnh mach noi, chon cho noi
ke va khong lay tron van tnh mach. Trong hai nam
au sau phau thuat, sang thng noi mac hoac x
hoa co the phat trien tai cho noi hoac trong cau
noi. Suy giai oan tre sau hai nam thng th phat
do s tiep tuc phat trien mang x va trong mach
mau goc oan gan va xa cho noi.
Hep. o van toc trong manh ghep noi trong
giai oan sm hoac tre sau mo co the dung e xac
nh tnh trang suy manh ghep. Bandyk va cs. cho
rang van toc nh tam thu di 40 en 45 cm/giay
gap trong suy manh ghep.46,47 Tieu chuan nay ch
xac nh cho tnh trang suy manh ghep nang.48
Tieu chuan nay khong xac nh v tr hep tien trien
mai en khi dong chay gii han va gay huyet
khoi.49 Cac sang thng thng do qua trnh tang
san lp si noi mac. Qua trnh tang san nay co the
theo doi dien tien chuyen nang. Co the s dung
Hnh 29-14. Phnh manh ghep noi mach mau. Mat
sieu am Doppler mau e khao sat ca oan dai
cat ngang cua phnh mach ln ngang cho noi pha xa cua cau
noi ong mach chu-ui cho thay hien dien dong chay dang manh ghep noi t 30 en 80 cm. Co the nhanh
cuon xoay ien hnh ben trong phnh mach. chong nhan ra v tr nghi ng hep va phan tch pho
Doppler co the xac nh mc o nang bang cach
dung t le van toc nh tam thu (Hnh 29-15). T le
noi. S gia tang van toc do hnh the khong gian cua nay c tnh bang cach chia van toc nh tam thu
cho noi la bnh thng va co the gia tang ti 100% o tai v tr nghi hep cho van toc o trc cho hep
van toc ma khong co benh ly i kem. Cha co mot 2 en 4 cm trong manh ghep (Hnh 29-8; Hnh 29-
nghien cu a ra tan suat that s nay va tnh quan 16). T le van toc bang hoac ln hn 2 tng ng
trong cua dau hieu nay. Theo doi anh gia cac v vi hep 50%; neu t le bang hoac ln hn 3
tr noi vai thang co the hy vong thay s phat trien
tng ng hep 75%.18,50 Nhieu so lieu gan ay
cho hep.45 Mat tn hieu Doppler trong can noi la
cho thay t le cao hn tng ng 75% hep.51
chan oan cua tac.
Phng phap nay rat chnh xac trong khao sat va
phan o hep.52-54 Gii han tiem an la sang thng
Manh ghep tnh mach t than
lien tuc tandem ma dong chay tai mot v tr hep
Hai loai cau noi tnh mach ang c s dung tai
chong len dong chay cho hep ke tiep.55 Cac ton
lap ong mach: tnh mach lon ngc (reversed) thng trong ba thang au sau phau thuat co the
va tnh mach tai cho (in-situ). Tnh mach lon ngc xac nh trc khi benh nhan co bieu hien trieu
la mot oan tnh mach nong goc lay t v tr giai chng.56 Can thiep tai tao dong chay tai cho hep
phau bnh thng, sau o lon ngc va sau o noi c ch nh khi xac nh c v tr hep.56,57 Neu
oan gan va oan xa ong mach tai oan b h. khong can thiep, mang ghep noi co the tac. oi
Ky thuat tai cho thng dung tnh mach hien ln vi chi tren, t le van toc nh tam thu tren 3 hoac 4
du tnh mach hien be co the dung trong phau thuat khong ro rang trong quyet nh can thiep ieu tr.
noi khoeo va ong mach chay-mac oan xa. Tnh Ro ong-tnh mach. Bien chng nay thng
mach c s dung thng nguyen v tr, lay bo xay ra vi ky thuat dung tnh mach tai cho. Lo ro
cac van va hai au nhanh noi c that. Cac oan ong-tnh mach nho co the bo sot trong phau thuat
gan va xa cua tnh mach c co nh va noi vi va hoac xay ra vai tuan sau mo. Sieu am Doppler
cac oan ong mach c chon. mau la phng phap khao sat n gian cac ro nay.
O4
Hnh 29-15. Hep manh noi mach mau. A, Phan nay cua noi tai cho ui-mac co vung nho van toc
cao cho thay hep (mui ten). B, dang pho Doppler tng ng thay gia tang van toc tai cho mau roi.
Hnh 29-16. Hep cho noi. A, Hnh cat doc cua cho noi cua cau noi cua ong mach chay sau cho thay
vung mau vt ngng aliasing tng ng ro vi hep. Kch thc bnh thng cua long mach tao hnh anh
mau gia v s tang toc tng oi cua te bao mau. B, Chup ong mach xac nh s hien dien cua hep pha xa
cho noi.
Co the s dung sieu am trong mo e nh v cho ro c thc hien gia ong mach va tnh mach
neu can phai giai phau thuat.46 Khong can ti quay (ky thuat Brescia-Cimino) thng c thay
quang ong mach, sieu am Doppler mau c coi the toan bang manh ghep cau noi (Hnh 29-17).
la phng tien hng dan duy nhat trong phau Manh ghep nay loai tong hp (PTFE
thuat khau ro thong lien gia tnh mach ghep tai polytetrafluorethylene ) hoac tnh mach t than
cho va tnh mach sau goc. c at tai cang tay. Van e chung cho ca hai
Ro cau noi trong loc mau (dialysis fistula). loai manh ghep nay bao gom phat trien phnh
Dung sieu am anh gia loai ro nay rat a dang.58,59 mach nho, phnh mach ln hn, gia phnh mach
Cau noi ong mach goc en tnh mach, thng hoac hep. Sieu am Doppler mau co the de dang
Hnh 29-17. Cac loai ro dung cho loc mau. Cac manh ghep chong (tan-ben) thng dung hn
loai Brescia-Cimino. Hau het cac cho hep nam tai hoac ngay sau cho noi tnh mach. Cac vat lieu dung
cho manh noi thng la loai tong hp mac du co the dung oan tnh mach t than.
Hnh 29-18. Manh ghep tong hp bnh thng. A, Hnh anh thang xam cho thay manh ghep tao bang
PTFE, chat lieu cua hau het cac manh ghep dung trong loc mau. Thanh thng hien len di dang hai ng phan
am. B, Dang song van toc Doppler ien hnh oi vi mot manh ghep bnh thng dung trong loc mau. Van toc
nh tam thu khuynh hng tren 100 cm/giay. Dong xoay thay di dang song b khong eu va mat ca so pho.
phat hien cac bat thng nay. Sieu am Doppler nhay tang len 95% va o chuyen biet 97%. Sieu
pho co the khao sat va phan o hep vi o chnh am Doppler mau dng nh khong cai thien o
xac 86% va o nhay 92% va o chuyen biet 84%.58 chnh xac cua chan oan.60
Co the giai thch s giam o chuyen biet la do Nhieu tac gia bao cao tieu chuan chan oan
kieu dong xoay tao nen bi lo trnh rat ngoan cua hep manh noi dung trong loc mau.61-63 Van toc
ngoeo cua manh ghep. o chnh xac cua chan nh tam thu trong manh noi tot thng khoang 100
oan cai thien ro oi vi manh ghep thang, o en 200 cm/giay (Hnh 29-18), hi cao hn trong 6
Hnh 29-19. Hep tai pha tnh mach cua manh ghep tong hp. A, Hnh thang xam cua khao sat Doppler
mau cho thay oan hep (mui ten) cua manh ghep. B, Dang song Doppler cho thay hien tng vt ngng mau va
van toc tren 500 cm/giay tai cho noi au tnh mach cua manh ghep. C, Dang song van toc Doppler bnh thng
khao sat tai manh ghep ngay trc hep
thang au sau ghep hoac tao thong noi.63 Kho

khao sat hep neu van toc nen cao (Hnh 29-19). S
gia tang 100% (t le van toc ln hn hoac bang 2)
thng do hep nang. Dong chay bang hoac thap
50 cm/giay cung la dau hieu hep nang. Sieu am
trang-en va Doppler mau hu ch trong xac nh
s thong noi (xem Hnh 29-19).62 Hep co khuynh
hng phat trien manh ghep pha tnh mach hn
80% trng hp.64 Hiem khi hep xay ra tnh
mach di on, ac biet trong trng hp loc mau
tam thi bang catheter lu co ng knh ln.65
Cac bien chng cua cac ky thuat xam lan

S dung sieu am Doppler mau va Duplex khao sat
benh nhan co can thiep bang ky thuat xam lan va
trong trng hp nghi ng ro ong-tnh mach va Hnh 29-20. Do ong tnh mach. Hnh anh mau cat
ngang qua chan phai cho thay kenh thong lien gia ong
gia phnh mach. Cac dau hieu trong sieu am
mach ui chung, CFA va tnh mach ui chung, CFV. Sieu am
thng c chap nhan nh ket luan, khong can ti pho cua CFV cho thay dang song xoay ong mach hoa.
chup quang ong mach. Benh nhan trai qua tai tao phau thuat khong can chup quang
Ro ong-tnh mach. Ro sau at catheter ong mach v thay ro thong lien tren hnh Doppler dong mau.
hoac cac ky thuat chup ong mach co the xac nh
bang sieu am Doppler mau.66,67 vung ui, vung
chay xoay co the thay trong tnh mach ui hoac Valsalva. Vi lo ro nho, van toc tnh mach co the
tnh mach ui sau vi tn hieu ong mach hoa giam trong khi lam Valsalva. Mat hoan toan tn
thay tren sieu am Doppler pho (Hnh 29-3). Cho hieu dong khi lam nghiem phap Valsalva gi y ro
ro thay tren sieu am Doppler mau; sieu am se tac trong vai tuan. Vi cac ro ln, van toc trong
Duplex mot mnh se gap kho khan khi nh v cho tnh mach khong giam ap ng vi Valsalva khi so
ro (Hnh 29-20). Dong chay xoay cua ro co the sanh vi tnh mach chi bnh thng. Ngi ta a
nham lan vi chen ep tnh mach t ben ngoai do mo ta phng phap ieu tr xuyen da nham ong
khoi mau tu thng la bien chng sau at catheter. cho ro bang cach theo doi di sieu am va ep tren
Thay c kenh thong lien cho phep chan oan tin cho ro khoang 20 en 60 phut.68 T le thanh cong
cay hien dien ro hn la chen ep t ngoai do mau khoang 30% 68 hoac kem hn.
tu. Dau hieu gian tiep cua ro la tnh trang gian Gia phnh. Bien chng nay co the xay ra sau
tnh mach va giam ap ng vi nghiem phap chan thng xuyen thau hoac at catheter ong
the dung ky thuat chen ep nay.75,76 Nhieu tac gia

lu y viec dung giam au giup giam bt kho chu
cho benh nhan khi chen ep keo dai. Bien chng ky
thuat nay la huyet khoi ong mach hoac tnh mach.
Tan suat gia phnh mach ngay cang tang.
Kresowik va cs. bao cao t le tan suat tang gap 10
lan so vi t le 0.5% a c bao cao cach ay vai
thap ky.77 Nguyen nhan cua s gia tang nay la do
s dung nhieu thuoc khang ong va catheter c ln
trong qua trnh tai tao mach mau. Mot bao cao gan
ay nhan manh vao tien oan cua tao lap gia
phnh mach la gii han thi gian chen ep sau khi
at catheter ong mach ui.78
THAM KHAO
Hnh 29-21. Gia phnh mach b huyet khoi/khoi
mau tu. Khoi phan am kem khong ong nhat nay ien hnh 1. Polak JF. Karniel Ml. Mannick JA et al. Determination of the
cho gia phnh mach b huyet khoi sau ieu tr thanh cong extent of lower - extrernitv peripheral arterial disease with color -
bang chen ep. Khoi mau tu co the co hnh anh tng t hoac assisted duplex sonography: comparison with angiography. AJR
co s tham nhiem lan toa lam bien dang nhe mo mem xung 1990; 155: 1085 - 1089.
quanh dung tuy la mot khoi s thay tren lam sang 2. deVrics S. Hunink M, Polak JF. Summary receiver operating
characteristic curves as a technique for mefa - analvsis for the
diagnostic performance of duplex ultrasonography in peripheral
arterial disease. Acad Radiol 1996: 3: 361 - 369.
mach. Nh a mo ta trong phan trc, dong chay Thiet b
cuon vong va co the xac nh cho thong noi trc 3. Barber FE. Baker DW, Nation AWC et al. Ultrasonic duplex
echo Doppler scanner. IEEE Trans Biomed Engin 1974; 21: 109 -
tiep gia gia phnh mach va long ong mach bang 113.
sieu am Doppler mau. Trong cac tnh huong cap 4. Kasai C, Namekawa K, Koyano A et al. Real - time two - dimen
cu, x ly gia phnh mach bang sieu am kha rong - sional blood flow imaging using an autocorrelation technique.
IEEE Trans Sonics Ultrasound 1985: 832: 458 - 463.
rai. Ban chat gia phnh mach thng la lanh tnh, 5. Polak JF, Dobkin GR, O'Leary DH et al. Internal carotid artery
vi huyet khoi va ro ong khi benh nhan ngh tai stenosis: accuracy and reproducibility of color - Doppler -
ging (Hnh 29-21).69 Fellmeth va cs. lan au tien assisted duplex imaging. Radiology 1989: 173: 793 - 798.
mo ta ieu tr xuyen da bang chen ep oi vi gia Cac kieu dong ong mach tren Doppler
6. Spencer MP, Reid JM. Quantitation of carotid stenosis with
phnh mach do at catheter. Cac tac gia nay a continuous - wave (C - W) Doppler ultrasound. Stroke 1979: 10:
ra cach tien hanh n gian bang cach ap mot lc 326 - 330.
trc tiep cua au do len co cua gia phnh mach. 7. Reneman R, Spencer M. Local Doppler audio spectra in normal
and stenosed carotid arteries in man. Ultrasound Med Biol 1979:
au do at doc theo truc ong mach khi xac nh 5: 1 - 11.
v tr do bat au ep chat. Gay tac thanh cong mat 8. Ojha M, Johnston K, Cobbold R et al. Potential limitations of
khoang 20 phut ep. Neu khong thanh cong lan center - line pulsed Doppler recordings: an in - vitro flow visual -
ization study. J Vasc Surg 1989; 9: 515 - 520.
au, co the lap lai ky thuat nay ba lan. Ky thuat 9. Middleton WD, Erickson S. Melson GL. Perivascular color
chen ep qua da co t le thanh cong 80% cac trng artifact: pathologic significance and appearance on color Doppler
hp a bao cao. Cac bao cao sau o cho thay ty le US images. Radiology - 1989; 171: 647 - 652.
10. Wilkinson DL, Polak JF, Grassi CJ et al. Pseudoaneurysm of the
thanh cong cao hn.70,71 Mac du nhng bao cao ban vertebral artery: appearance on color - flow Doppler sonography
au cho thay t le thap neu benh nhan ang dung AJR 1988; 151: 1051 - 1052.
chong ong, mot bao cao gan ay lai cho thay ty 11. Mitchell DG. Color Doppler imaging: principles, limitations, and
artifacts. Radiology 1990; 177: 1 - 10.
le thanh cong cao oi vi benh nhan dung chat
12. Abu - Yousef MM, Wiese JA, Shamma AR. The "to - and - fro"
khang ong.72 Cac bao cao khac cho rang t le se sign: duplex Doppler evidence of femoral artery pseudo -
cao hn oi vi phnh mach nho va oi vi thong aneurysm. AJR 1988; 150: 632 - 634.
13. Morion MJ, Charboneau JW, Banks PM. Inguinal
lien dai.73,74 oi vi gia phnh mach phat sinh t lymphadenopathy simulating a false aneurysm on color - flow
ong mach nach va ong mach canh tay cung co Doppler sonography. AJR 1988; 151: 115 - 116.
14. Bjork L, Leven H. Intra - arterial DSA and duplex - Doppler 34. Mewissen MW, Kinney EV, Bandyk DF et al. The role of duplex
ultrasonography in detection of vascularized inguinal lymph scanning versus angiography in predicting outcome after balloon
node. Acta Radiol 1990; 31: 106 - 107. angioplasty in the femoropopliteal artery. J Vasc Surg 1992, 15:
15. Musto R, Roach M. Flow studies in glass models of aortic 860 - 866.
aneurysms. Can J Surg 1980; 23: 452 - 455. 35. Sacks D, Robinson ML, Summers TA et al. The value of duplex
sonography after peripheral artery angioplasty in predicting
Benh ly ong mach ngoai bien
subacute stenosis. AJR 1994: 162: 179 - 183.
16. Newman AB, Siscovick DS, Manolio TA et al. Ankle - arm index
36. Katzenschlager R, Ahmadi A, Minar E et al. Color duplex
as a marker of atherosclerosis in the Cardiovascular Health
ultrasound guided transluminal angioplasty of the femoro -
Study. Circulation 1993: 88: 837 - 845.
popliteal artery: initial and 6 - months results. Radiology 1996;
17. Cronenwett JL, Warner KG, Zeienock GB et al. Intermittent
199: 331 - 334:
claudication. Current results of nonoperative management. Arch
37. Vroegindeweij D, Tielbeek A, Buth J et al. Directional atherec -
Surg 1984; 19: 430 - 436.
tomy versus balloon angioplasty in segmental femoropopliteal
18. Kohler TR, Nance DR, Cramer MM et al. Duplex scanning for
artery disease: two - year follow - up with color - flow duplex
diagnosis of aortoiliac and femoropopliteal disease: a prospective
scanning. J Vasc Surg 1995; 21: 255 - 268.
study. Circulation 1987; 76: 1074 - 1080.
38. Tielbeek A, Rietjens E, Buth J et al. The value of duplex
19. Gooding GA, Effeney DJ. Ultrasound of femoral artery
surveillance after endovascular intervention for femoro -
aneurysms. AJR 1980; 134: 477 - 480.
popliteal obstructive disease. Eur J Vasc Endovasc Surg 1996; 12:
20. MacGowan SW, Saif MF, O'Neil G et al. Ultrasound examination 145 - 150.
in the diagnosis of popliteal artery aneurysms. Br J Surg 1985;
39. Spijkerboer A, Nass P, de Valois J et al. Iliac artery stenoses
72: 528 - 529.
after percutaneous transluminal angioplasty: follow - up with
21. Shortell CK, DeWeese JA, Ouriel K et al. Popliteal artery duplex ultrasonography. J Vasc Surg 1996: 23: 691 - 697.
aneurysms: a 25 - year surgical experience. J Vasc Surg 1991; 14:
771 - 779. Manh ghep noi
22. Jager KA, Phillips DJ, Martin RL et al. Noninvasive mapping of8 40. Hedgcock MW, Eisenberg RE, Gooding GA. Complications
lower limb arterial lesions. Ultrasound Med Biol 1985; 11: 515 - relating to vascular prosthetic grafts. J Can Assoc Radiol 1980;
521. 31: 137 - 142.
23. Cossman DV, Ellison JE, Wagner WH et al. Comparison of 41. Polak JF, Donaldson MC, Whittemore AD et al. Pulsatile masses
contrast arteriography to arterial mapping with color - flow surrounding vascular prostheses: real - time US color flow
duplex imaging in the lower extremities. J Vasc Surg 1989; 10: imaging. Radiology 1989; 170: 363 - 366.
522 - 529. 42. Nichols WK, Stanton M, Silver D et al. Anastomotic aneurysms
24. Fleteher FP, Kershaw LZ, Chan A et al. Noninvasive imaging of following lower extremity revascularization. Surgery 1980; 88:
the superficial femoral artery using ultrasound duplex scanning. J 366 - 374.
Cardiovasc Surg 1990; 31: 364 - 367. 43. Helvie MA, Rubin JM, Silver TM et al. The distinction between
25. Whelan FF, Barry MH, Moir JD. Color flow Doppler ultra - femoral artery pseudoaneurysms and other causes of groin
sonography: comparison with peripheral arteriography for the masses: value of duplex Doppler sonography. AJR 1988; 150:
investigation of peripheral arterial disease. J Clin Ultrasound 1177 - 1180.
1992; 20: 369 - 374. 44. Coughlin BF, Paushter DM. Peripheral pseudoaneurysms:
26. Mulligan SA, Matsuda T, Lanzer P et al. Peripheral arterial evaluation with duplex US. Radiology 1988; 168: 339 - 342.
occlusive disease: prospective comparison of MR angiography 45. Sanchez LA, Suggs WD, Veith FJ et al. Is surveillance to detect
and color duplex US with conventional angiography. Radiology failing polytetrafluoroethylene bypasses worthwhile: twelve -
1991; 178: 695 - 700. year experience with 91 grafts. J Vasc Surg 1993; 18: 981 - 990.
27. Moneta GL, Yeager RA, Antonovic R et al. Accuracy of lower 46. Bandvk DF, Jorgensen RA, Towne JB. Intraoperative assessment
extremity arterial duplex mapping. J Vasc Surg 1992; 15: 275 - of insitu saphenous vein arterial bypass grafts using pulsed
284. Doppler spectral analysis. Arch Surg 1986; 121: 292 - 299.
28. Moneta GL, Yeager RA, Lee RW et al. Noninvasive localization 47. Bandyk DF, Cato RF, Towne JB. A low flow velocity predicts
of arterial occlusive disease: a comparison of segmental failure of femoropopliteal and femorotibial bypass grafts. Surgery
pressures and arterial duplex mapping. J Vasc Surg 1993: 17: 578 1985: 98: 799 - 809.
- 582. 48. Mills JL, Harris EJ, Taylor LM Jr. et al. The importance of
29. Karacagil S, Lofberg A, Granbo A et al. Value of duplex routine surveillance of distal bypass grafts with duplex scanning:
scanning in evaluation of crural and foot arteries in limbs with a study of 379 reversed vein grafts. J Vasc Surg 1990: 12: 379 -
severe lower limb ischemia. A prospective comparison with an 389.
giography. Eur J Vasc Endovasc Surg 1996; 12: 300 - 303. 49. Grig MJ. Nicolaides AN, Wolfe JH. Detection and grading of '
30. Elsman BH, Legemate DA, van der Heijden FH et al. Impact of fem orodistal vein grafts stenoses: duplex velocity measurements
ultrasonographic duplex scanning on therapeutic decision making compared with angiography. Vase Surg 1988: 8: 661 - 666.
in lower limb arterial disease. Br J Surg 1995; 82: 630 - 633. 50. Hunink MGM, Polak JF. Response to commentary on accuracy of
31. Collier P, Wilcox G, Brooks D et al. Improved patient selection color Doppler flow mapping for evaluation of the severity of
for angioplasty utilizing color Doppler imaging. Am J Surg 1990; femoropopliteal arterial disease: a prospective study. JVIR 1991:
160: 171 - 174. 2: 477 - 478.
32. Edwards JM, Goldwell DM, Goldman ML et al. The role ot 51. Ranke C, Creutzig A, Alexander K. Duplex scanning of the
duplex scanning in the selection of patients for transluminal an - peripheral arteries: correlation of the peak velocity ratio with an -
gioplasty. J Vasc Surg 1991; 13: 69 - 74. giographic diameter reduction. Ultrasound Med Biol 1992; 18:
33. Polak JF, Karmel Ml, Meyerovitz MF. Accuracy of color Doppler 433 - 440.
flow mapping for evaluation of the severity of femoropopliteal 52. Londrey GL, Hodgson KJ, Spadone DP et al. Initial experience
arterial disease: a prospective study. JVIR 1991; 2: 471 - 479. with color - flow duplex scanning of infrainguinal bypass grafts. J
Vasc Surg 1990: 12: 284 - 290.
53. Polak JF, Donaldson MC, Dobkin GR et al. Early detection of 67. Roubidoux MA, Hertzberg BS, Carroll BA et al. Color flow and
saphenous vein arterial bypass graft stenosis by color - assisted image - directed Doppler ultrasound evaluation of iatrogenic ar -
duplex sonography: a prospective study. AJR 1990; 154: 857 - teriovenous fistulas in the groin. J Clin Ultrasound 1990; 18: 463
861. - 469.
54. Bnth J, Disselhoff B, Sonuneling C et al. Color - flow duplex 68. Fellmeth BD, Roberts AC, Bookstein JJ et al. Postangiographic
criteria for grading stenosis in infrainguinal vein grafts. J Vasc femoral arterv injuries: nonsurgical repair witli US - guided
Surg 1991; 14: 716 - 728. compression. Radiology 1991; 178: 671 - 675.
55. Leng GC, Whyman MR, Donnan PT et al. Accuracy and re - 69. Kotval PS, Khoury A, Shah PM et al. Doppler sonographic
producibility of duplex nitrasonography in grading femoro - demonstration of the progressive spontaneous thromhosis of
popliteal stenoses. J Vasc Surg 1993; 17: 510 - 517. pseudoaneurysms. J Ultrasound Med 1990: 9: 185 - 190.
56. Mills JL, Bandyk DF, Gathan V et al. The origin of infrain - 70. Fellmeth BD, Baron SB, Brown PB et al. Repair of post -
tniinal vein graft stenosis: a prospective study based on duplex catheterization femoral pseudoanenrysms by color flow ultra -
surveillance. J Vasc Surg 1995; 21: 16 - 25. sound guided compression. Am Heart J 1992; 123: 547 - 55U.
57. Tdu MM, Blankestein JD, de Gier P et al. Impact of a color - 71. Cox GS, Young JB, Gray BB el al. Ultrasound - guided com -
flow duplex surveillance program on infrainguinal vein graft pression repair of postcatheterizatioii pseudoaneiirysms: results
patcncy: a five - year experience. J Vasc Surg 1993; 17: 42 - 53. of treatment in one hundred cases. J Vasc Surg 1994; 19: 683 -
58. Tordoir JH, de Bruin HG, Hoeneveld H et al. Duplex ultra - 686.
sound scanning in the assessment of arteriovenous fistulas 72. Dean S, Olin J, Piedmonte M et al. Ultrasound - guided com -
created for hemodialysis access: comparison with digital pression closure of postcatheterization pseudoaneurysms during
subtraction angiography. J Vasc Surg 1989; 10: 122 - 128. concurrent anticoagulation: a review of seventy - seven patients.
59. Scheible W, Skram C, Leopold GR. High resolution real - time J Vasc Surg 1996; 23: 28 - 35.
sonography of hemodialysis vascular access complications. AJR 73. DiPretc DA, Cronan JJ. Compression ultrasonograpliy: treatment
1980; 134: 1173 - 1176. for acute femoral artery pseudoanenrysms in selected cases. J
60. Middleton WD, Picus DD, Marx MV ct al. Color Doppler Ultrasound Med 1992; ! 1: 489 - 492.
sonographv of hemodialysis vascular access: comparison with 74. Paulson FK, Hertzberg BS, Paine SS et al. Feuioral artery
angiography AJR 1989: 152: 633 - 639. pseudoaneurysms: value of color Doppler sonograpliy in
61. Koksoy C, Kuzu A, Erden I et al. Predictive value of colour predicting which ones will thrombose without treatment. AJR
Doppler sonographv in detecting failure of vascular access grafts. 1992; 159: 1077 - 1081.
Br J Surg 1995; 82: 50 - 52. 75. Rooker KT, Morgan CA, Haseman MK et al. Color How guided
62. Dousset V, Grenier N, Douws G et al. Hemodialysis grafts: color repair of axillary artery pseudoaneurysm. J Ultrasound Med
Doppler flow imaging correlated with digital subtraction ang - 1992; 1: 625 - 626.
iography and functional status. Radiology- 1991; 18: 89 - 94. 76. Skibo L, Polak JF. Compression repair of a postcathetcrizalion
63. Villemarette P, Hower J. Evaluation of functional longevity of pseudoancurvsm of tlie brachial artery under sonographic
dialysis access grafts using color flow Doppler imaging. J Vasc guidance. AJR 1993; 160: 383 - 384.
Tech 1992; 16: 183 - 188. 77. Kresowik TF, Klioury MD, Miller BV et al. A prospective study
64. Kanterman RY, Vesely TM, Pilgram TK et al. Dialysis access of the incidence and natural history of femoral vascular
grafts: anatomic location of venous stenosis and results of an - complications after percutaneous transluminal coronary angio -
gioplasty. Radiology 1995; 195: 135 - 139. plasty. J Vasc Surg 1991; 13: 328 - 335.
65. Schwab'SJ, Quarles LD, Middleton JP et al. Haemodialysis - 78. Katzensclilager R, Ugurluoglu A, Ahmadi A et al. The incidence
associated subclavian vein stenosis. Kidney Int 1988; 33: 1156 - of pseudoaneurysm after diagnostic and therapeutic an -
1159. giography. Radiology 195; 1995: 463 - 466.
66. Altin RS, Flicker S, Naidech HJ. Pseudoaneurysm and arteri -
ovenous fistula after femoral artery catheterization: association
with low femoral punctures. AJR 1989; 152: 629 - 631.
C H N G 3 0
Cac tnh mach ngoai bien

Bradley D. Lewis, M.D.
DAN BAI
CAC PHNG PHAP
PHNG PHAP
Cac phng phap khao sat sinh ly, anh gia lam sang cua he thong tnh mach ngoai
khong xam lan, khong bang hnh anh bien thng kho va khong chnh xac. Co rat nhieu
Phng phap khao sat bang hnh anh, phng phap khao sat bang hnh anh va khong
co xam lan quang tnh mach bang hnh anh ang c phat trien e giup cac
Phng phap khao sat bang hnh anh, nha lam sang chan oan benh. Cac phng phap
khong xam lan sieu am nay co the chia thanh ba nhom chnh.
THIET B
Hnh anh hoc theo thang xam
Cac phng phap sinh ly, khong xam lan
Sieu am Doppler
va khong bang hnh anh.
CAC TNH MACH CHI DI
Giai phau hoc
Cac phng phap nay da tren thay oi cua huyet
Huyet khoi tnh mach sau ong hoc tnh mach e gian tiep chan oan benh.
Dau hieu lam sang Th du, ky thuat anh gia tnh mach bang cach o
Kham, khao sat s thay oi the tch chi ( plethysmographic) va sieu
Cac ho tr trong kham, khao sat am Doppler dang s dung song lien tuc. Nhn
Cac dau hieu chung, cac ky thuat nay rat chu quan, phu thuoc
o chnh xac ngi lam, thieu tnh chuyen biet, va ky thuat nay
Huyet khoi tnh mach sau man tnh khong co tnh xac nh ve giai phau. Tuy nhien,
( DVT man ) cac ky thuat nay re va co the dung nh mot chc
Suy van nang khao sat ban au va hu ch oi vi cac nha
Sinh ly benh lam sang gioi va kinh nghiem.
Khao sat
Cac dau hieu Cac phng phac khao sat bang hnh anh
Ve s o tnh mach (vein mapping)
xam lan quang tnh mach
S dung tnh mach cho ghep mach t
Quang tnh mach cho thay cau truc giai phau cua
than
he thong tnh mach va la tieu chuan vang cua
anh dau tnh mach xuyen b suy
CAC TNH MACH CHI TREN hnh anh tnh mach so vi cac phng phap khac.
Giai phau hoc Tuy nhien, phng phap nay ton tien, xam lan,
Lam sang nguy c cua phan ng vi chat can quang du la
Huyet khoi tnh mach thap, va viem tnh mach sau chup quang tnh mach.
Kham Cac khuyet iem nay dan ti viec giam dan ng
Dau hieu dung ky thuat nay. Ky thuat nay cung khong anh
o chnh xac gia c ve sinh ly mach mau.
Phng phap khao sat bang hnh anh, tan so cang cao neu thay c vung can khao sat
khong xam lan sieu am th se cho hnh anh tot hn ve o phan giai.
Hnh anh thi gian thc trong sieu am thang xam,
sieu am Doppler pho duplex va sieu am Doppler Sieu am Doppler
mau cung cap thong tin giai phau khach quan Ky thuat nay bao gom phan tch Doppler pho ve
giong nh quang tnh mach va thong tin sinh ly ve nh lng va Doppler mau ve khao sat nh tnh
huyet ong hoc cua tnh mach. dong chay. Ca hai ong vai tro chu chot trong
Sieu am vi u iem : gia re, khong xam lan, chan oan va xac nh mc o khach quan tnh
co may nhieu ni, c ong va tnh chnh xac cao. trang benh ly trong cac tnh mach ngoai bien. Sieu
Sieu am ong vai tro quan trong trong chan oan am co the anh gia thay oi ve huyet ong hoc.
huyet khoi tnh mach. Sieu am cung anh gia tnh ay chnh la u the sieu am trong anh gia benh
trang suy tnh mach, ve s o cay tnh mach, va mach mau ve giai phau va sinh ly. Cac au do
anh gia tnh thong thoang cua tnh mach trc khi linear, phased array c dung vi tan so thap kem
at catheter tnh mach. chc nang sieu am Doppler. Nhieu au do co kha
Cac phng phac khac cung co kha nang anh nang oi hng quet cua chum song trong sieu am
gia he thong tnh mach ngoai bien. Chup XQCLT Doppler tai v tr co goc o ma oc lap vi goc o
tiep tuc phat trien vi ky thuat xoan oc hoac dung cua chum song am e tao hnh anh theo thang
CLT-chum tia ien t. Cac ky thuat nay nh xam. Do vay, cac goc o Doppler v tr nong co
giam thieu thi gian ghi hnh va cho phep chup the ap dung va lam giam mc sai so tao bi cac
mach mau, chu yeu khao sat he thong ong mach goc o Doppler qua ln. Cac yeu to nay cang
nhng cung co the khao sat tnh mach. Cong thay ro khi khao sat ong mach. Sieu am Doppler
hng t va chup mach mau bang cong hng t dong chay mau cho hnh anh tng t hnh anh
(MRA) ang tiep tuc phat trien va cho nhieu ha dong chay trong sieu am trang en. Cac d lieu
hen trong chan oan he thong tnh mach ngoai nh tnh cho biet ve van toc tng oi cua dong
bien. Khong co cac u iem giong nh sieu am chay, vung co dong xoay, va chieu cua dong chay.
trong chan oan benh tnh mach ngoai bien, Sieu am Doppler mau n gian hoa va giam thi
XQCLT va CHT hiem s dung, tr trong mot so gian khao sat trong sieu am benh mach mau. Ky
tnh huong kho. thuat nay cho phep khao sat nhanh chong mot
oan dai cua he thong tnh mach va co the cung
THIET B cap thong tin quan trong, ac biet oi vi cac phan
oan khong the dung ky thuat ep tnh mach nh
Hnh anh hoc thang xam tnh mach di on, hoac tnh mach benh nhan
Sieu am tnh mach ngoai bien hau het cho hnh co the tang ln hoac beo ph.
anh vi o phan giai cao do v tr tng oi nong
cua tnh mach va khong co hi ruot hoac cac cau TNH MACH CHI Di
truc xng che chan. Do v tr tng oi nong,
ngi thc hien nen s dung au do tan so cao. Giai phau
hau het benh nhan, au do thang vi tan so 5 MHz He thong tnh mach chi di chia lam he thong
cho phep toi u hnh anh theo thang xam khi khao nong va sau. He thong tnh mach nong bao gom
sat tnh mach ui, khoeo, va di on. Trong hau tnh mach hien ln, tnh mach hien be va cac
het benh nhan the tang ln, hoac khao sat tnh nhanh cua chung. Tnh mach hien ln t mat trong
mach chau, hoac trong xac nh huyet khoi lan toa cua tnh mach ui chung tai oan gan cua ui, pha
tnh mach chu di, nen dung au do tan so 3,5 di day chang ben va tren cho chia oi tnh m ach
MHz e khao sat c o sau can thiet. oi vi (Hnh 30-1). Tnh mach hien ln chay di da, doc
cac tnh mach nong nh tnh mach hien ln, tnh mat trong ui va cang chan xuong ti ban chan.
mach hien be, tnh mach canh tay va tnh mach Tnh mach hien ln bnh thng co ng knh 1
cang chan phan xa, nen dung au do tan so cao 7.5 en 3 mm tai mat ca va 3 en 5 mm tai ni noi
MHz e hnh anh ro hn. Trong sieu am, au do tnh mach hien-tnh mach ui.
Cac tnh mach ngoai bien 945
Hnh 30-1. Giai phau hoc cac tnh mach chi di

Tnh mach hien be co v tr o vao khong co xng chay. Khao sat oan gan cua tnh mach
nh tai mat sau cua oan gan hoac oan gia cua chay sau se kho khan benh nhan c bap hoac
tnh mach khoeo. Tnh mach hien be chay doc beo ph. Tuy nhien, tnh mach nay de xac nh khi
theo mat sau vung cang chan ti mat ca. Bnh chung i qua pha sau mat trong xng mat ca va
thng oan xa kch thc 1-2 mm ng knh; 2-4 co the khao sat t di len.
mm tai ni noi tnh mach khoeo va tnh mach nay Co rat nhieu tnh mach sau dan lu cho c
c dung tot trong ghep t than cua nhieu benh vung cang chan. Tnh mach vung c bung chan va
nhan. Khi co tnh trang suy tnh mach nong, tnh vung c dep khong co ong mach i kem va
mach hien ln va be tr nen to bat thng hoac thng co kch thc va chieu dai thay oi. Cac
gian. tnh mach nay la mot ni tao huyet khoi tnh mach
anh gia tnh mach chi di thng lien quan sau cap tnh benh nhan co nguy c cao hoac hau
trc tiep ti he tnh mach sau. Tnh mach ui phau. Tuy nhien, s thay oi cua cac tnh mach
chung bat au tai v tr day chang ben, la s noi nay lam cho viec anh gia tnh mach va huyet khoi
tiep vi tnh mach chau ngoai, nam ben trong va tnh mach khong ay u.
sau canh ong mach ui chung (Hnh 30-1). Tnh
mach ui chung chia oi thanh tnh mach ui sau Huyet khoi tnh mach sau (DVT)
va nong tai oan gan ui, cach day chang ben Tam quan trong lam sang. Ngi ta khong
khoang 6-8 cm va vai centimet cach cho chia oi ro ty le that cua DVT (deep venous thrombosis)
cua ong mach ui. Tnh mach ui sau tiep tuc cap tnh va bien chng nghiem trong cua DVT la
chay doc mat trong, tng ng vi ong mach, khi phu phoi. Moi nam chan oan khoang 50.000
vao sau chay hng ra ngoai dan lu mau cac c trng hp phu phoi tai Hoa Ky, va cac nghien cu
ui. Tnh mach ui sau phan nhanh nhieu nhng giai phau t thi cho thay ch 19% phu phoi la co
thng ch co the khao sat oan gan. trieu chng nghi ng tren lam sang. Khoang
Tnh mach ui nong chay doc xuong gia lp 200.000 benh nhan nhap vien moi nam e ieu tr
can, di c may, ben trong c t au ui va ben DVT cap nhng phan ln cac benh nhan nay khong
ngoai c khep. Tnh mach ui nong nam pha ben co trieu chng. Kho khan trong chan oan chu yeu
trong ong mach ui ti luc i qua ong c khep la do tnh khong chnh xac cua anh gia lam sang.
tai oan xa ui. Ong c khep tao bi s tach ra Cac dau hieu va trieu chng cua DVT cap bao
cua cho bam tan cua gan c khep ln. Ong nay gom : au, o va sng. Cac dau hieu nay khong
nam sau trong phan ui xa bao gom mo gan va bao chuyen biet va co the do cac tnh trang cuc bo
si than kinh. Tai v tr nay, ky thuat sieu am ep hoac toan than gay ra. Dau hieu s c dang day
tnh mach gap kho khan. Sau khi i qua ong c do tac tnh mach, hau het xay ra oi vi viem tac
khep, tnh mach nay tr thanh tnh mach khoeo tnh mach nong do huyet khoi, thng khong lien
trong khoang khoeo. Tai v tr nay, tnh mach quan ti DVT cap. Cac trieu chng tren gop phan
khoeo nam nong hn ong mach khoeo, va tiep tuc giup lam sang chnh xac khoang 50% trong chan
i xuong phan tren cang chan. oan DVT cap benh nhan co trieu chng. Thc
Nhanh au tien cua tnh mach khoeo la hai te, hau het cac benh nhan nhap vien co nguy c
tnh mach chay trc, chay doc theo ong mach cao hnh thanh DVT cap th khong co trieu chng.
vao trong khoang trc cua cang chan. Cac tnh Trong phong labo mach mau cua chung toi, ch co
mach nay chay xuong di va doc mat trc mang 374 trong 2489 benh nhan (15%) trong nam 1995
gian cot ti phan lng cua ban chan. Ngay sau nghi ng DVT cap co dau hieu sieu am dng tnh.
goc tnh mach chay trc, than tnh mach chay- Do DVT cap khong ieu tr la mot chan oan lam
mac chia oi thanh hai tnh mach mac va hai tnh sang kho khan va co the co cac bien chng nghiem
mach chay sau. Tnh mach mac nam canh ong trong bao gom phu phoi, hoi chng sau viem tnh
mach mac va pha trong cua mat sau xng mac. mach. DVT oi hoi cac phng phap chan oan
Xng mac la moc quan trong cho viec xac nh chnh xac va khong xam lan. Nhieu nghien cu va
cac tnh mach nay. Tnh mach chay sau chay kinh nghiem lam sang chng minh sieu am la ky
theo ong mach sau cua c cang chan, pha sau thuat hoan hao cho chan oan.
Hnh 30-2. Ky thuat sieu am ep tnh mach bnh thng. Hnh

anh cat ngang cua ong mach ui chung, A va tnh mach ( mui ten) trc khi
e ep va sau khi ep vi au do. Tnh mach bnh thng se hoan toan xep
khi b e ep.
Khao sat. anh gia he thong tnh mach sau sieu am Doppler pho ( duplex) cua tnh mach ui
chan tren benh nhan nghi ng co DVT cap chu yeu chung trong khi lam nghiem phap Valsalva co the
da tren sieu am thang xam vi ky thuat ep tnh cho dau hieu gian tiep s thong thoang tnh mach
mach tren mat ngang va sieu am Doppler mau. oan gan trong vung chau. Bnh thng, dong
au do thang 5 MHz phu hp vi hau het cac benh chay tnh mach lien tuc-hng ti co s thay oi
nhan. Vi ap lc nhe ep tren chan theo mat ngang nhe theo chu ky th. Trong nghiem phap Valsalva,
vuong goc vi truc tnh mach bang au do thang, co thi ky ngan vi dong chay ngc, theo sau
tnh mach bnh thng xep hoan toan va thanh tnh ngay la khong co dong chay v s gia tang ap lc o
mach hai ben ap sat nhau (Hnh 30-2). Mc o e bung. Khi khong co ap dung nghiem phap Valsalva
ep thay oi tuy theo o sau va v tr cua tnh mach (ngh la luc ap lc o bung giam ot ngot), thay s
nhng thng ap lc phai nho hn ap lc cua ong gia tang ot ngot dong chay tnh mach hng ti
mach ke can. roi nhanh chong tr ve ng c ban ban au
Benh nhan nam t the nga. Chan dang ra, (Hnh 30-3, A). benh nhan b tac nghen hoan
xoay ngoai va co nhe au goi. Khao sat chuan bat toan tnh mach chau chung hoac tnh mach chau
au t tnh mach ui chung ngay di day chang ngoai se lam giam hoac bien mat dong chay ma
ben. Thay tnh mach va ep tnh mach theo mat bnh thng co thay oi theo ho hap. Khong co s
ngang tng oan cach nhau moi 2 en3 cm doc thay oi dang pho nay khi lam nghiem phap
xuong di ti tnh mach ui nong oan xa trong Valsalva (Hnh 30-3, B). Co the thay dong chay
ong c khep. Tnh mach ui sau oan gan va tnh tnh mach cham trong hnh anh ong cua sieu am
mach hien ln thng thay va khao sat c trong trang en v co the thay c phan am cua huyet
mat phang ngang nay. Thng anh gia tnh mach khoi. Nghiem phap Valsalva cung cap chng c
khoeo tot nhat khi nam xap va ban chan duoi nhe sinh ly gian tiep cua s thong thoang tnh mach t
va au goi co nhe. T the nam nghieng ben trai tnh mach ui chung en tnh mach chu di. Co
khao sat tng oi tot. Trong t the nay, mat ep the gap khao sat am tnh gia v huyet khoi mot
ngang co the ap dung doc v tr chia ba cua tnh phan-khong gay tac cua tnh mach chau hoac benh
mach khoeo. Co the ap dung nhieu thao tac hoac nhan co nhieu tuan hoan bang he. Chung lam cho
ky thuat ho tr khac cho ky thuat ep tnh mach. nghiem phap Valsalva ap ng bnh thng. oi
vi benh nhan om, co the khao sat trc tiep tnh
Cac ho tr khao sat. Thng khong khao sat mach chau vi au do 3,5 MHz.
tnh mach vung chau v hnh anh khong ro do v tr Sieu am Doppler mau la mot ho tr co ch
nam sau va hi ruot chen pha trc. Tuy nhien , cho ky thuat khao sat chuan ep tnh mach. Trong
Hnh 30-3. Khao sat tnh mach chau vi nghiem phap Valsalva. A, Hnh anh doc cua phan ng bnh
thng cua tnh mach ui chung, CFV, benh nhan khoe manh. Hnh anh Doppler pho cho thay phan ng bnh
thng oi vi nghiem phap Valsalva: chu ky ngan vi dong chay ngc va theo sau la thi ky khong co dong
chay. Ngay sau khi ngng nghiem phap Valsalva, REL, dong chay tr lai bnh thng. B, Phan ng bat thng-
hnh anh Doppler pho mot benh nhan khac cho thay s giam ro ret dong chay va khong phan ng vi nghiem
phap Valsalva. Tnh mach nay co the xep hoan toan ( khong minh hoa). C, Quang tnh mach cua tnh mach chu
di va tnh mach chau cho thay tac tnh mach chau chung ben phai ( mui ten) do benh ly hach di can.
tnh mach bnh thng, mau phai lap ay long Benh nhan co the nam sap, nam nghieng trai hoac
mach t b nay sang b kia, co t hoac khong co t the ngoi. Nang ban khao sat t the
hien tng vt ngng mau (color- aliasing) ngoai Trendelenburg quay ngc hoac cho benh nhan
long mach. Tang lu lng lu thong tnh mach ngoi e de khao sat khi tnh mach cang chan gian.
bang bop vung cang chan thng can thiet e tao Khao sat cac cap tnh mach chay sau, tnh mach
mau lap ay long mach mau. Sieu am mau co the mac vi au do tai mat sau cang chan. Sieu am
hu dung trong anh gia cac oan tnh mach ma mau ket hp vi ky thuat tang lng lu thong tnh
kho thay do the tang benh nhan hoac do v tr cua mach e xac nh tnh thong thoang cua tnh
phan oan c khao sat. Sieu am Doppler mau mach. Co the anh gia cac tnh mach chay trc
cung co thuan li hn ky thuat ep tnh mach trong t mat trc. Tuy nhien huyet khoi rieng re vung
benh nhan DVT man. nay rat hiem do vay khao sat pha trc khong can
Khao sat tnh mach cang chan bang sieu am thiet khi a khao sat cac tnh mach chay sau va
thang xam vi ky thuat ep tnh mach va sieu am mac va ket luan bnh thng. Cac tnh mach sau
Doppler mau. Ngi ta con ang tranh luan gia tr cua vung c bung chan va c dep khong co nh
lam sang va hieu qua kinh te cua khao sat nay. ve kch thc va co kha nang khao sat c, nen
Tai nhieu trung tam y khoa, khong khao sat tnh khong bat buoc khao sat thng qui nhng nen chu
mach vung cang chan do co rat hietn DVT rieng re y neu thay.
vung cang chan gay phu phoi tram trong. Tuy Mot cach bo sung cua khao sat chuan c e
nhien tai mot so trung tam khac, khao sat vung ngh e tiet kiem thi gian khao sat. Gii han ky
cang chan la thng quy neu co trieu chng tai cho thuat ep tnh mach ch thc hien tren tnh mach ui
do cac huyet khoi vung cang chan co nguy c tao chung va khoeo oi vi benh nhan co trieu chng
huyet khoi oan gan vi t le 20%, lam tang t le se tiet kiem rat nhieu thi gian, nhng o nhay
hoi chng tnh mach, va suy tnh mach tram trong giam. ieu nay co the ro v huyet khoi hiem xay
neu khong ieu tr huyet khoi vung cang chan. Do ra rieng re tnh mach ui nong hoac tnh mach
s khac nhau tren, e khao sat he thong tnh mach chau, v huyet khoi vung cang chan t quan trong
ui-khoeo c chnh xac, co the khao sat cac ve lam sang va v hieu qua kinh te do giam thi
phan cua he thong tnh mach sau cang chan trong gian khao sat. Frederick va cs. bao cao gan ay t
nhieu benh nhan. le 4,6% tac tnh mach rieng re cua tnh mach ui
Hnh 30-4. Thuyen tac tnh mach sau cap do huyet khoi. A, Hnh anh ngang cua tnh mach khoeo,
POP VN, cho thay mat kha nang xep tnh mach va thay phan am ben trong tnh mach cua huyet khoi. B,
Sieu am Doppler theo m at cat doc cho thay khong co dong chay va phan am trong long tnh mach khoeo v
tac hoan toan do huyet khoi. POP ART, ong mach khoeo
Hnh 30-5. Cac thuan li cua sieu am Doppler mau. A, Tac hoan toan do huyet khoi cua hai tnh
mach chay sau (V) hai pha cua ong mach chay sau; (A) sieu am Doppler mau mat cat doc cua cang chan,
can thiet cho anh gia tnh mach cang chan. B, Sieu am vi ky thuat ep mach khong ap dung tot cho tnh
mach ui nong oan xa trong ong c khep. C, tnh mach va ong mach ui nong oan xa bnh thng.
Sieu am Doppler mau mat cat ngang tren cung mot benh nhan. Sieu am mau giup thay cac oan sau tnh
mach benh nhan co the tang ln.
CAC BAY TRONG CHAN OAN DVT CAC DAU HIEU TRONG DVT MAN
Huyet khoi cap co the khong co phan am Giam ng knh tnh mach hoac teo nho mot so
Huyet khoi ban cap hoac man co the khong lam oan
gian tnh mach Thanh tnh mach day va khong eu
Huyet khoi khong gay tac co the cho phan ng Thieu mau dang li phan am trong long mach
bnh thng tren nghiem phap Valsalva Khong co DVT cap
Cac tnh mach tuan hoan bang he vung chau Khong gian tnh mach vi huyet khoi phan am kem
nhieu co the cho phan ng bnh thng khi hoac ang am
lam nghiem phap Valsalva Kem suy tnh mach sau
Nghiem phap Valsalva ch co gia tr khi ap dung Co tnh mach tuan hoan bang he
tren goi
sieu am thang xam. Do vay mat kha nang ep tnh

mach hoan toan la c s e chan oan DVT (deep
DAU HIEU CUA DVT CHI DI venous thrombosis). Gian to tnh mach do huyet
khoi co the gap cap tnh nhng thng t thay hn
Sieu am Sieu am khi huyet khoi a lau va tr nen co cau truc ro.
ep tnh mach Doppler mau Khong thay nhng thay oi ng knh tnh mach
theo ho hap va nghiem phap Valsalva trong benh
Tnh mach xep Hnh khuyet trong long
nhan co DVT. Tuy nhien, dau hieu nay thng ch
khong hoan toan van ton tai
thay oan gan ui va thng khong co ch di
Thay huyet khoi phan Cang gian tnh mach
am do huyet khoi cho chia oi cua tnh mach ui chung.
Gian to tnh mach do Khong co dong chay iem noi bat cua sieu am Doppler mau oi
huyet khoi vi DVT da tren xac nh cho thieu hut lam ay
Mat thay oi theo nhp mau (thieu mau) long mach mau hoac huyet khoi
th tren sieu am pho quanh cot mau trong long tnh mach (Hnh 30-4,B)
hoac khong co dong chay. Sieu am mau xac nh
mc o tac nghen tnh mach va phan thong thng
con lai cua long mach. Sieu am mau rat hu dung
nong. Sieu am vi ky thuat ep tnh mach gii han trong cac oan tnh mach ui, chau va tnh mach
v tr khao sat lam giam o chnh xac can lam ro. cang chan (Hnh 30-5).
Sieu am vi ky thuat ep tnh mach toan bo t tnh Tnh chnh xac. Tnh chnh xac va ng dung
mach ui chung ti tnh mach khoeo oan xa la lam sang cua anh gia DVT bang sieu am ang
tieu chuan khao sattnh mach ui nong. Sieu am c nghien cu rong rai. Dan so benh rat quan
vi ky thuat ep tnh mach gii han v tr khao sat trong va nen xem xet trong hai nhom ln, co trieu
lam giam o chnh xac can lam ro. Sieu am vi ky chng va khong co trieu chng. Trong nhom co
thuat e ep toan bo tnh mach t tnh mach ui trieu chng, vai nghien cu so sanh vi tnh mach
chung ti tnh mach khoeo oan xa la tieu chuan ky, sieu am vi ky thuat ep tnh mach co o nhay
khao sat. 95% va chuyen biet 98%. Cac nghien cu nhom
Cac dau hieu. Cac dau hieu cua ep tnh khong trieu chng, benh nhan co nguy c cao hoac
mach tren khao sat bang sieu am kieu B cua DVT hau phau co ket qua kem hn. Vai ket qua cua sau
cap thng da tren hnh anh trc tiep cua huyet cong trnh nghien cu cho thay o nhay trung bnh
khoi va mat kha nang ep tnh mach (Hnh 30-4). 59% va chuyen biet la 98% trong nhom dan so
Hnh anh huyet khoi rat a dang, phu thuoc vao nay. Huyet khoi rieng re vung cang chan nhom
mc o, tuoi va mc phan am cua huyet khoi. benh nhan nay co t le cao, ban chat khong gay tac
Khong may, vai huyet khoi co the co phan am va kch thc nho; ro rang lam cho o nhay thap v
trong va co the bo sot neu ch khao sat bang nhng yeu to tren lam chan oan sieu am kho
Hnh 30-6. Tac tnh mach sau do huyet khoi man. A, sieu am Doppler mau mat doc cua tnh
mach ui nong va sau cho thay s khiem khuyet mau va li phan am trong long mach ui nong, SFV
(mui ten). B, tnh mach ky xac nh s thay oi cua tac tnh mach sau do huyet khoi DVT man (mui ten).
C, sieu am Doppler mau mat doc tren benh nhan khac thay thanh mach day bat thng cua tnh mach ui
nong oan gan vi ng knh mach giam (mui ten). D, tnh mach ky xac nh cac dau hieu cua DVT
man (mui ten). DFV, tnh mach ui sau( Trch t Lewis BD, James EM, Welch TJ va cs. Diagnosis of
acute deep venous thrombosis of the lower extremities: prospective evaluation of color Doppler flow
imagimg versus venography. Radiology 1994;192:651-655
khan so vi quang tnh mach. Vi cac ket qua tren, e trong hau het cac trung tam y khoa. Mac du,
benh nhan ly tng cho anh gia bang sieu am la sieu am co the giup trong mot so trng hp, hien
co trieu chng lan tren au goi. tai vai tro sieu am trong chan oan DVT man van
Huyet khoi tnh mach sau man tnh. Kha con cha ro.
nang phan biet DVT cap hoac man la van e kho Khi huyet khoi lau ngay, no trai qua qua trnh
khan tren lam sang va sieu am. Hang loat nghien to chc si hoa vi hien tng co cuc mau, tac
cu benh nhan vi DVT cap cho thay ti 53% benh nghen man hoac thanh mach day xay ra tai oan
nhan nay co dau hieu bat thng vi ky thuat ep tnh mach lien quan. Cac thay oi nay lam khao
tnh mach bang sieu am, thc hien t 6 ti 24 thang sat huyet khoi kho hn va dan ti ep tnh mach
sau khi co DVT. Cac benh nhan nay co hoi chng khong hoan toan. Mac du ky thuat ep tnh mach
tnh mach va co trieu chng giong DVT cap. ieu tren sieu am ong vai tro khong ang ke trong
tr bang chong ong khong ch nh cho cac benh chan oan DVT man. Nhieu tac gia cho rang sieu
nhan nay. Quang tnh mach la tieu chuan chan am mau co vai tro trong phan biet DVT cap va
oan hnh anh e phan biet DVT cap hoac man. man. Cac dau hieu cua DVT man trong sieu am
Tuy nhien, xem xet ve gia ca va s xam lan, quang mau bao gom thanh tnh mach phan am va khong
tnh mach khong phai ong vai tro giai quyet van eu, thanh tnh mach day do huyet khoi co, giam
Hnh 30-7. Suy tnh mach sau. A, Sieu am Doppler pho tnh mach khoeo,
POP V. cho thay phan ng bnh thng oi vi tang lu lng tnh mach pha xa,
AUG. B, Sieu am Doppler pho benh nhan khac cho thay suy tnh mach sau ro,
bang dong chay ngc can bang vi dong chay ti khi ngng tang hoi lu REL.
ng knh long tnh mach, cac oan tnh mach u e tao ra tnh trang suy van. Phan tch sieu am
teo, tuan hoan bang he phat trien, suy tnh mach pho tai nhieu v tr cua he thong tnh mach nong va
sau kem theo, hoac khong thay gian tnh mach do sau trong khi ap dung cac ky thuat. Sieu am pho
huyet khoi phan am trong kem hoac ang am. doc theo tnh mach ui chung va tnh mach hien
Du cac dau hieu nay ngh ti DVT man va rat ln oan gan vi nghiem phap Valsalva. Sieu am
quen thuoc vi cac nha hnh anh hoc, o chnh xac pho he thong tnh mach nong va sau ti v tr tnh
va vai tro cua sieu am mau van cha c ro rang. mach khoeo va tnh mach hien tai au goi. Tang
dong chay ngc bang bop ui pha tren hoac tang
Suy tnh mach hoi lu tnh mach pha xa chuan bang bop vung
Sinh ly benh. Trong nhieu benh nhan, DVT cang chan co the s dung e anh gia tnh trang
dan ti ton thng van tnh mach va gay ra suy tnh suy. Tuy nhien, tang hoi lu oan xa hieu qua hn
mach. To chc si hoa va co cuc mau th phat anh va de dang hn oi vi ngi khao sat thc hien
hng len cac van ke can. ieu nay dan ti suy mot mnh.
tnh mach sau trong khoang 50% benh nhan co Cac dau hieu. Sau khi tang hoi lu oan xa,
DVT cap. Vi suy tnh mach, co s anh hng trc dong chay bnh thng la hng ti vi mot thi
tiep cua ap lc thuy tnh cua cot dch ng trong he gian ngan cua dong chay ngc do mau chay
tnh mach xuong phan xa cua chi. Ve lam sang, ngc ong cac van tnh mach au tien con nguyen
suy tnh mach lam chan phu ne, thay oi da man ven (Hnh 30-7, A). Tnh mach suy co dong chay
tnh va thay oi sac to, va cuoi cung la cac vet loet ngc nhieu hn trong thi gian dai hn (Hnh 30-
do tnh trang tnh mach khong lanh. 7, B). anh gia ve mc o bang cach anh gia
Suy tnh mach nong dan ti tnh trang gian to nh dong chay ngc va o thi gian ma dong
tnh mach di da nhng tien lng tot hn nhieu. chay ngc xay ra. Tuy nhien, cac dau hieu nay
Tnh mach xuyen noi he thong tnh mach nong va cha co hieu qua ro va can c kiem chng them
sau va co the suy v tnh trang he tnh mach sau cho moi labo.
suy keo dai.
Khao sat. Khao sat vi t the benh nhan Ve s o tnh mach
ng thang hoac ng thang nghieng mot ben S dung tnh mach cho ghep t than. Ve
(semi-upright) vi trong lng c the don len chan s o va anh dau bang sieu am rat hu ch trong
oi ben. T the nay rat can thiet e tao ap lc nhieu benh nhan trc khi mot tnh mach c
Hnh 30-8. Tnh mach thong suy. Hnh cat ngang va hnh Doppler
pho cua tnh mach noi gian tai vung gia cang chan cho thay dong chay
To and Fro khi lam nghiem phap tang lu lng dong chay pha xa.
Tnh mach noi gian to va thong noi vi tnhg mach nong gian to.
dung cho ghep t than. Bat c tnh mach nong nao xuyen nam pha di goi va vung gia cang chan.
eu co the dung nhng tnh mach hien ln la thch Benh nhan t the ng thang, cac tnh mach
hp nhat cho ghep t than. Viec khao sat thc hien xuyen gian to co the thay chung i t mo di da
vi benh nhan t the nam nga hoac xuyen qua can vao lp c cang chan. Sieu am
Trendelenburg. Mot tourniquet hoac mieng quan kieu B co the thay ro cac tnh mach nay va dung
trong may o huyet ap vi ap lc s dung la 40 sieu am pho va ky thuat tang lu lng tnh mach
mm Hg ap len quanh vung ui oan gan e gay xac nh cac tnh mach nay suy (Hnh 30-8). Cac
gian tnh mach giup cho ve s o. Tnh mach hien tnh mach xuyen con nguyen ven thng co khau
c xac nh va anh dau t cho noi ui-hien knh nho va kho thay ro.
xuong ti ni xa nhat ma co the khao sat c.
Nen anh dau tat ca cac iem cua cac nhanh ln CAC TNH MACH CHI TREN
cua tnh mach e tr giup cho cac nha phau thuat.
Tnh mach nong ien hnh dung cho ghep t than Giai phau hoc
co ng knh 2 mm, khong c gian se thch hp Mau tnh mach tr ve t chi tren thng theo
cho ghep. Tnh mach hien be, tnh mach nen, va tnh mach ngoai canh tay va tnh mach nen. Tnh
tnh mach canh tay au la cac tnh mach ke tiep mach ngoai chay doc trong mo m di da cua mat
c chon la cho ghep t than va co the dung neu ngoai cua canh tay. Tnh mach nay noi vi he
tnh mach hien ln khong u. thong tnh mach sau tai mat tren cua tnh mach
anh dau tnh mach xuyen b suy Cac ky nach hoac oan xa tnh mach di on (Hnh 30-9).
thuat phau thuat mi trong that noi soi di can Tnh mach nen nam nong va doc mat trong cua
(subfascial endoscopic ligation) cua tnh mach canh tay. Tai v tr c ngc ln, tnh mach nay noi
xuyen c s dung tai mot so trung tam trong vi cac tnh mach sau cua canh tay. Tnh mach
ieu tr cac thay oi huyet ong tnh mach man va canh tay nho hn, sau hn, va nam ke can ong
cac loet tnh mach khong lanh. Cac ky thuat nay mach canh tay. Tnh mach nay noi vi tnh mach
c tr giup bang xac nh chnh xac va anh dau tnh mach nen tai v tr c ngc ln tao thanh tnh
tnh mach xuyen b suy. Phan ln cac tnh mach mach nach. Tnh mach nach nam canh va nong so
Hnh 30-9. Giai phau cua tnh mach chi tren. IJV: tnh
mach canh trong
vi ong mach nach tnh t c ngc ln va xng canh tay la do at cac dung cu nh catheter tnh
sn th nhat. mach trung tam, day dan may tao nhp. Trong
Khi tnh mach nach ngang qua xng sn th trng hp co catheter trung tam, 26-67% hnh
nhat, oi ten thanh tnh mach di on. Tnh mach thanh huyet khoi du a so khong co trieu chng.
di on nam nong so vi ong mach ke can va Xa tr, ieu tr khac, va tac nghen do u ac tnh xam
di xng on. Phan trong tnh mach di on lan la nhng nguyen nhan tac nghen tnh mach
nhan mau cua tnh mach canh ngoai va tnh mach thng gap vung ngc va canh tay hn la chi
canh trong tai nen co tao than tnh mach canh tay- di. Du nguyen nhan DVT cap vung chi tren va
au. Tnh mach canh trong t lo canh tai nen so di khac nhau, nhng c che sinh ly benh khi
ti hp lu vi tnh mach di on. Tnh mach phat giong nhau.
canh trong chay doc theo can canh va nam nong- Di chng cua tac tnh mach do huyet khoi chi
ben cua ong mach canh chung vung co trc. tren t tram trong hn chi di. Ch khoang 10-
Tnh mach canh trai phai thng khong oi xng 12% benh nhan vi DVT canh tay dan ti bien
ve kch thc. Tnh mach canh tay au tao t s chng phu phoi cap va hau het cac trng hp nay
hp lu cua tnh mach canh trong va tnh mach khong nguy kch. S phat trien va hnh thanh tnh
di on. Tnh mach canh tay au phai chay doc trang suy tnh mach do DVT chi tren thng t
mat tren cua trung that tren-phai. Tnh mach tay xay ra va t tram trong. Phu man tnh, thay oi da,
au ben trai dai hn, t trung that tren-ben trai qua va loet tnh mach khong lanh rat hiem chi tren.
ben phai trc khi i xuong xng c. Hai tnh Thc te nay do hai yeu to chnh: th nhat, s hnh
mach canh tay au noi lai tao tnh mach chu tren. thanh vo so tnh mach bang he sau DVT hoac tac
tnh mach chi tren hoac vung ngc; th hai, tnh
Lam sang mach chi tren khong chu ap lc thuy tnh nh chi
Hau het cac ch nh dung sieu am anh gia di. Tac nghen man tnh do lien quan ti at
tnh mach chi tren la xac nh tac tnh mach do catheter tnh mach va tac tnh mach do huyet khoi
huyet khoi. Nguyen nhan va dau hieu lam sang tao kho khan trong at tnh mach trung tam oi
quan trong cua DVT cap chi tren khac vi DVT benh nhan noi tru hoac co benh man tnh. Sieu am
cap chi di. Hau het cac trng hp cua DVT la phng phap ly tng xac nh v tr choc tnh
Hnh 30-10. So sanh tnh mach di on

bnh thng va b tac. A, Tnh mach di
on bnh thng, SCV. Sieu am Doppler tren
mat ngang va Doppler pho. Thay mau lap ay
mach mau va thay oi bnh thng theo nhp
tim. B, Mat thay oi theo nhp tim tren mat cat
ngang cua tnh mach di on trai tren mot benh
nhan khac. C, Tac tnh mach di on( mui ten)
vi vo so tuan hoan bang he.
mach. Trong trng hp kho, sieu am hng dan mach di on va tnh mach canh tay au oan
at catheter tnh mach la can thiet. tren. Vi ca so khao sat hng xuong theo mat
phang tran va ngay tren xng on, dung sieu am
Huyet khoi tnh mach Doppler mau khao sat tnh mach canh tay au
Kham. anh gia he thong tnh mach chi tren oan tren va tnh mach di on oan gia. Phan
va vung ngc tren thng t phan tren cua tnh tch sieu am pho tnh mach canh trong oan di,
mach canh tay au en tnh mach nach va tnh tnh mach canh tay au oan tren va tnh mach
mach canh tay. Tnh mach canh trong cung c di on oan gia da tren nhp ap tim va thay
khao sat. Benh nhan thng nam nga vi canh oi theo ho hap. V rat gan tim, cac v tr nay co
tay hi dang va xoay ngoai. au benh nhan hi anh hng ro ret bi nhp tim va ho hap, so vi
nghieng ve oi ben. Dung au do tan so cao vi khao sat chi di. Mat anh hng nhp tim tren
o xuen thau can thiet. Thng dung 7,5 MHz pho khao sat, co the do tac nghen tnh mach gan
au thang cho tnh mach canh trong va tnh mach trung tam (Hnh 30-10). So sanh Doppler pho vi
nach va tnh mach canh tay. Dung au do thang 5 chi tren oi ben thng giup trong xac nh co
MHz co chc nang mau e khao sat tnh mach hay khong co tac nghen tnh mach. ap ng trong
di on. nghiem phap Valsalva va nhay mui (sniffing) co
anh gia he thong tnh mach vung ngc tren the thay va gop phan xac nh tnh thong thng
va canh tay thng kho khan ve mat ky thuat hn
khao sat chi di. Trc het, cac cau truc xng
che pha trc va phoi lam khong the khao sat trc CAC DAU HIEU HUYET KHOI TNH MACH
tiep tnh mach canh tay au va tnh mach chu tren. CHI TREN
Ke en, xng on khong cho phep dung ky thuat
sieu am ep tnh mach di on. Th ba, s phat Ep khong hoan toan
trien manh cua tuan hoan bang he lam cho ket qua Doppler mau cho thay hnh khuyet trong long
khao sat am tnh gia neu khong khao sat c tuan mach van ton tai
Mat hoac giam nhp ap cua tim truyen ve
hoan bang he nay. Do cac nguyen nhan tren, sieu
Bieu hien bat thng khi lam nghiem phap ho hap
am Doppler mau, khao sat t m va hieu biet ve
Cac tnh mach bang he ln
tng quan giai phau bnh thng la cot loi.
Khao sat tnh mach canh trong bang ky thuat
ep tnh mach trong mat ngang ti cho noi vi tnh
Hnh 30-11. Huyet khoi tnh mach di on cap. Sieu am

Doppler tnh mach di on mat cat ngang cho thay huyet khoi phan
am kem lan rong vi dong chay vung ngoai bien nho.
cua tnh mach. Bnh thng neu benh nhan nhay interpretation of signs and symptoms. Angiology 1969;20:219-
223.
mui, tnh mach canh trong va di on se giam
4. Barnes RW, Wu KK, Hoak JC. Fallibility of the clinical diagnosis
kch thc va phan tch pho se thay s gia tang van of venous thrombosis. JAMA 1975;234:605-607.
toc mau. Benh nhan co tac nghen tnh mach canh 5. Lewis BD, James EM, Welch TJ et al. Diagnosis of acute deep
tay au trung tam hoac tnh mach chu tren se mat venous thrombosis of the lower extremities: prospective evalu-
ation of color Doppler flow imaging versus venography
ap ng nay khi lam nghiem phap nhay mui. Radiology 1994;192:651-655.
Tnh mach di on kho khao sat vi hnh 6. Rose SC, Zwiebel WJ. Nelson BD et al. Symptomatic lower ex-
anh toan ven. Ca so tran, tren on, hng xuong tremity deep venous thrombosis: accuracy, limitations, and
role of color duplex flow imaging in diagnosis. Radiology 1990;
s dung oi vi pha trong va ca so tran, di 175:639-644.
on, hng len s dung oi vi pha ngoai. oan 7. Polak JF, Culler SS, O'Leary Dll. Deep veins of the calf: assess-
tnh mach chay sau di xng on thng khong ment with color Doppler flow imaging. Radiology- 1989:171:
481-485.
cho hnh anh ay u. V b xng on che chan,
8. Atri M, Herba MJ, Reinhold C et al. Accuracy of sonography in
nen can thiet dung sieu am Doppler mau e xac the evaluation of calf deep vein thrombosis in both postopera-
nh tnh thong thng cua tnh mach. Ngi khao tive surveillance and symptomatic patients. AJR 1996:166:
sat nen xac nh quan he nong-sau cua ong mach 1361-1367.
va tnh mach e tranh sai lam khi co he thong tuan 9. Pezzullo JA, P erkins AB, Cronan .T.I. Symptomalic deep vein
thrombosis: diagnosis with limited compression US. Radiology-
hoan bang he cua tnh mach di on trong benh 1996:198:67-70.
nhan co tac nghen man tnh. Co the anh gia tnh 10. Frederick MG, Ilertzberg BS, Kliewer MA et al. Can tlie US ex-
mach nach va canh tay oan gan bang ky thuat amination for lower extremity deep venous thrombosis be ab-
breviated? A prospective study of 755 examinalions. Radiology-
sieu am ep tnh mach hoac sieu am Doppler. Dien
1996;199:45-47.
tch khao sat phu thuoc vao ch nh lam sang 11. Cronan JJ. Venous thromboembolic disease: the role of US.
nhng thng khao sat ti cho chia oi cua ong Radiology 1993:186:619-630.
mach nach. 12. Weinmann EE, Saizrnan EW. Deep-vein thrombosis. N Engl J
Med 1994:331:1630-1641.
Cac dau hieu. Cac dau hieu bnh thng va 13. Cronan JJ- Leen V. Recurrent deep venous thrombosis: limita-
bat thng trong tnh mach chi tren tng t trong tions of US. Radiology' 1989:170:739-742.
tnh mach chi di. Huyet khoi tnh mach se khong 14. Baxter CM, Duffy P, MacKechnie S. Colour Doppler ultrasound
of the post-phlebitic limb: sounding a cautionary note. Clin
cho dau hieu ep dnh tnh mach hoan toan. Thay Radiol 1991:43:301-304.
huyet khoi hoac khiem khuyet mau trong long tnh
Cac tnh mach chi tren
mach khi sieu am Doppler (Hnh 30-11 trang 957). 15. Bonnet F, Joriferne JF, Texier JP et al. Evalualion of Doppler
Giam hoac mat anh hng nhp tim hoac ho hap examination for diagnosis of catheter-related deep vein throm-
tren doppler pho hoac mat ap ng khi lam nghiem bosis. Intensive Care Med 1989;15:238-240.
16. McDonough JJ, Altemeier WA. Subclavian venous thrombosis
phap nhay mui. Trong trng hp tac nghen tnh
secondary to indwelling catheters. Surg Gynecol Obstet 1971:
mach man thng co he thong tuan hoan bang he 133:397-400.
ro. 17. Horatlas MC, Wright DJ, Fenton AH et al. Changing concepts
of deep venous thrombosis of the upper extremityreport of a
o chnh xac. Tnh chnh xac cua sieu am so
series and review of the literature. Surgery 1988:104:561-567.
vi quang tnh mach trong benh nhan co DVT cap 18. Becker DM, Philbrick JT, Walker FB IV. Axillary and subclavian
chi tren cha c nghien cu rong rai. Theo venous thrombosis. Prognosis and treatment. Arch Intern Med
cac nguyen van hien tai, sieu am co o nhay 78- 1991:151:1934-1943.
19. Monreal M, Lafoz E, Ruiz J et al. Upper-extremity deep venous
100% va o chuyen biet 92-100%. o chnh xac
thrombosis and pulmonary embolism. A prospective study.Chest
chi tren b thap hn la do nhieu bat li ve mat ky 1991;99:280-283.
thuat khi khao sat tnh mach chi tren. 20. Knudson GJ, Wiedmcyer DA, Erickson SJ et al. Color Doppler
sonographic imaging in the assessment of upper-extremity deep
venous thrombosis. AJR 1990;154:399-403.
THAM KHAO
21. Baxter CM, Kincaid W, Jeffrey RE et al. Comparison of colour
Cac tnh mach chi di Doppler ultrasound with venography in the.diagnosis of axillary
1. Sandier DA, Martin JF. Autopsy proven pulmonary embolism in and subclavian vein thrombosis. Br J Radiol 1991;64:777-781.
hospital patients: are we detecting enough deep vein thrombosis? 22. Morion MJ, James EM, Welch TJ et al. Duplex and color
J Roy Soc Med 1989;82:203-205.
Doppler imaging in the evaluation of upper extremity and tho-
2. Saizman EW. Venous thrombosis made easy (editorial). N Engl J
racic inlet deep venous thrombosis (exhibit). AJR 1994:16
Med 1986:314:847-848. (suppl):192
3. Haeger K. Problems of acute deep venous thrombosis. I. The

Ultrasound Rumak-Vietnamese Full

Uploaded by

Copyright:

Available Formats

Ultrasound Rumak-Vietnamese Full

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ultrasound Rumak-Vietnamese Full

Uploaded by

Copyright:

Available Formats

C H N G 1 5

T cung va phan phu

Hnh 15-8. ong voi do loan dng lp trong cua

Hnh 15-11. Bat thng t cung. A, Sieu am qua

Hnh 15-12. Xem chu thch trang oi dien

Hnh 15-14. Leiomyosarcoma. Sieu am cat ngang qua

Hnh 15-18. mau am ao benh nhan tre vi

khang cua estrogen; phu n sau man kinh va

Hnh 15-31. Dch tang phan am tui cung sau (mui

NGACH TRC TRANG T CUNG (TUI

Tui cung sau la phan pha sau va pha trong nhat

kch thch cua hormone kch thch nang (FSH) va

Hnh 15-33. Buong trng bnh thng sau khi man

Hnh 15-40. Xoan buong trng. A, Hnh cat doc gia

Hnh 15-41. Ung th buong

ba lp te bao mam c biet hoa ro ngoai b,

Hnh 15-49. U quai dang nang (cystic teratoma).

phan biet chnh la u Brenner hay u x t cung co

Hnh 15-51. U vo-si (fibrothecoma) buong trng vi s thoai hoa

Benh viem vung chau truyen qua ng sinh

Hnh 15-54. Benh ly viem vung chau. Hnh anh sieu am

vi nhng khoi phan phu lanh tnh va ac tnh khac, Carcinoma

s thong thng vi bang quang va s thay oi

NHNG BENH LY VUNG CHAU THI KY

Nhng benh ly trong thi ky hau san thng la hau

1991 :78:70-76. cell tumors of the ovary: radiologic-pathologic correlation.

Sieu am Phan mem, ong mach Canh

hieu qua va tiet kiem, ieu quan trong la phai nam

ben trong nhan va cac dau nhan tren mang nhan)

HNH ANH IEN HNH CUA CARCINOMA

Khoi u ac giam phan am

cung nh xam lan mo giap lan can. Ca hai bien the

AC TNH SIEU AM CUA CARCINOMA

b carcinoma tuy hn carcinoma nhu (Hnh 21-14).

Hnh 21-14. Huyet khoi trong tnh mach canh trong

AC TNH SIEU AM CUA CARCINOMA GIAM

Khoi giam phan am

Lymphoma. Lymphoma chiem khoang 4%

Hawkins va cs.41 1399 2,4 4,6 86 95

thanh cong FNA tren lam sang rat le thuoc vao

o nhay cam thap (36%) va khong u tin cay e

Trong nhng nam gan ay, nhieu bai bao e

theo tuoi va theo gii.71 Trong so 1000 benh nhan

BENH LAN TOA CUA TUYEN GIAP

Tuyen can giap

khoang gia-tren cua tuyen giap. a so cac trng

CNG CAN GIAP NGUYEN PHAT

giap. Adenoma cua tuyen can giap tren trong

Cach kham sieu am Cac v tr lac cho

adenoma sau kh quan. Adenoma trong trung that. V tr thng thay

ADENOMA TUYEN CAN GIAP: NHNG

Mach mau noi phnh len

rieng, cac tuyen phnh to nay co hnh anh sieu am

CNG CAN GIAP TH PHAT Trng hp dng tnh gia

Hnh 22-17. Nhan tuyen giap giong vi adenoma

xng tng t v c dai co la cau truc oi nam ca

Hnh 22-18. Sinh thiet kim qua da adenoma tuyen can

Hnh 22-19. Huy adenoma tuyen can giap bang con.

HUY KHOI U BANG CON